Exercise in education and medicine

Front matter

lb

A.

Class JxlMJ Book ^^3

Preface

The followins: pages are addressed to students and practitioners of physical training; to teachers of the youth; to students of medicine and to its practitioners, with the purpose to give a comprehensive view of the space exercise should hold in a complete scheme of education and in the treatment of abnormal or diseased conditions.

The recognition of physical education by teachers has been retarded by dabblers and self-elected professors of one or other systems, whose extravagant claims have done much to obscure the real educational value of neuromuscular training; for the / result of physiologic research in the growth and development of the nervous system is just beginning to be applied in the classification and design of exercise, to harmonize it with the conclusions of proved science.

Exercise has so many points of contact with education, it is so intricately related to mental, moral, and social training, each of which alone is so partial and incomplete, that the progressive educationalist is now compelled to study its bearing on all three.

It is of vital importance that the student of physical training should have a broad and catholic foundation on which to build the structure of his experience, and that he shall consider and balance the merits and limitations of systems and ideas coming from diverse lands. The normal schools and colleges of physical training are lengthening their courses and broadening their curriculum to meet this increasing need, and, with more thoroughly educated instructors, there will be less seen of a certain superciliousness with which the whole subject is regarded by some otherwise well-informed physicians.

12 PREFACE

The progress of medxal science has been most notable in the great questions of national health and prosperity involved in the feeding, housing, and exercise of the people. School boards are appealing for medical inspection of the children to discover correctable defects and to prevent the spread of disease. The pern cious influence of indoor life on growth has been proved, and measures arc now taken to remedy it by exercise and play; city slums are replaced by playgrounds, colleges and universities are placing on their curriculum instruction in physical education, both practical and theoretical, since the necessity for exact knowledge of the physical characteristics which differentiate the child from the youth, and both from the adult, has become patent to the thoughtful physician whose advice is so constantly asked.

Exercise and massage have been used as remedial agencies since the days of ^Esculapius, but definite instruction in their use has seldom been given to medical students. Perhaps a certain laziness which is inherent in both patient and physician tempts to the administration of a pill or draught to purge the system of what should be used in normal muscular activity, but there is a wide dearth of knowledge among the profession of the scope and application of exercise in pathologic conditions, and the necessity of care in the choice and accuracy of the dosage will be emphasized throughout the second part of this book.

I have endeavered to acknowledge in the text the sources from which facts are culled, but I must especially acknowledge my indebtedness to the inspiring friendship of my colleague, Dudley A. Sargent, to E. M. Hartwell, from whose classic reports to the U. S. Bureau of Education, much of the historical data relating to gymnastic systems was obtained; also to Fred. E. Leonard, of Oberlin, whose historical researches on ! physical education have been mined with rich results. The studies of Luther Halsey Gulick, on the development of plays among children, and G. Stanley Hall's work on Adolescence have been most serviceable sources of inspiration, while the chapters on exercise for the blind, deaf, and mental defectives have been founded on the work of Edward Allen, Grace Green,

PREFACE 13

and Maurice Barr, in their respective specialties. In the section on medical treatment I have striven to credit other workers in the field with the contributions they have made, but much of it is my own experience, gathered from a special practice in the application of exercise.

I trust that this book may help to place before the profession this Cinderella of the therapeutic family in her true character.

R. T. M.

Philadelphia, Pa.

July, 1909.

Chapter I

The term exercise, as here employed, comprises all movements, voluntary or passive, including manipulations by the hand of an operator or by a machine, designed to act on the muscles, the blood-vessels, the nervous system, the skin, and the abdominal organs.

This wideness of definition is necessary to cover its application and its efi&cacy as a medicinal agent.

It naturally falls into the two main divisions given by Plato — active and passive.

1. Active exercise requires a definite exertion of the will power, whether in its more complicated form of games and gymnastics, or in simple duplicate directed movements with assistance or resistance by the hands of an operator or by a machine.

2. Passive exercise does not require any exertion of will power. The various manipulations of massage, by means of the hands, or by the machines of Zander and others, by which contracted ligaments or muscles are stretched and nourished, local nutrition improved, nerves stimulated, and the abdominal organs affected, are restful rather than exhausting to an overwrought brain.

Active exercise may be subdivided into, first, those involving a single effort of one or more muscle groups, such as lifting a weight or performing a feat on the parallel bars; and, second, 2 17 exercises of endurance, consisting of motions rhythmically repeated without great muscular expenditure for each one, and depending for their effect upon continuous repetition.

Exercises of effort may be more or less violent in character or compound in motion, each one starting from and ending with rest. They are in endless variety, from simple movements of lifting and throwing, to the complicated combinations on the parallel bars and horizontal bar. In them the element of skill plays a leading rdle, and what would be a mild exercise for the expert may be a severe strain to the beginner, whose inaccuracy means the clumsy employment of many muscles that help little in its accomplishment, the contraction of some groups actually retarding success. Even in the accurate performance of an apparently simple movement, the distribution of muscular effort is wide, and increases tremendously with the difficulty of the feat. In pushing a heavy dumb-bell to arm's length above the shoulder, the extensors of the elbow-joint are the ones usually considered, but the entire muscular system shares in the effort. The grasping muscles of the hand are required, also the muscles that raise the shoulder and rotate the scapula. These are attached to the spine and ribs, which in turn must be supported by the pelvis, steadied on the hips, while the balance of the body is preserved by the muscles of the thigh and legs.

A single, simple effort, then, may give rise to fatigue of more than the muscles most obviously employed.

Education should be directed to teaching skill in the performance of such movements — skill that tends to economize the amount of effort required — for it is the common experience of shotputters to find that their record performance is accomplished with the greatest ease, owing to the smooth, accurate application of group after group of muscles at the proper time; and the perfection of balance and speed of the body's movement.

However skilful the performer may be, the whole muscular system participates in any violent exercise of effort. During the intense concentration so necessary for success, the chest-walls are fixed; the glottis is closed, the lungs acting as an air cushion for the surrounding cage of ribs and diaphragm; all the muscles of the trunk are steadied, and when the effort is made there is an explosive discharge of nervous energy, the intensity of which is mirrored in the muscular rigidity of the athlete's face.

Fig. I. — The typical face of violent effort seen in sprinting, hammer-throwing, or spurting in a distance race (modeled from life by the author).

The face of such a man will show a general converging of the lines to the root of the nose, with transverse wrinkles over the bridge. The frowning brows are drawn down and the eye is narrowed to a mere slit. The outer angle of the eye shows the "crow's feet " accompanying all violent action of the muscles that close it. The nose and upper Up have a snarling expression, the nostrils are distended, and the lower lip is drawn tightly across the clenched teeth, except at the angles of the mouth, where there are little pouches caused by the pulling of the platysma, which

Stands out along the neck like cords. The general impression of the face is repulsive and corresponds closely to the face of rage as described by Darwin.^ The lips, however, are more retracted than during the purely emotional state and the clenched teeth are exposed, presenting the appearance of one in readiness for tearing o^ seizing the enemy.

Fig. 2. — The expression of effort seen in throwing the hammer.

In his drawing of rage Sir Charles BelP shows a face corresponding closely in many respects to this one of strain.

The eyes are shut with force in all violent effort, such as shouting, sneezing, crying, or laughing, where the compression of the heart and lungs, by the muscular contraction of the chest-walls, drives up the blood-pressure to the point of seriously endangering the delicate vessels of the eye from overdistention, the hammer-thrower or the sprinter would shut them if he could. Indeed, the hammer-thrower often does close his eyes at the moment of greatest effort. The great skin muscle of the neck, the platysma, springs

^ " Expression of the Emotions in Man and Animals." " " Expression of the Emotions.''

into action wherever violent effort is performed, as in delivering a blow, and sometimes even in testing the grip by the dynamometer. It is the muscle of emphasis.

Games and feats of speed, in which many movements must be repeated as quickly as possible in a certain limited time, may well be classed as exercises of effort, since practically all the conditions of a single effort apply to them.

In a loo-yard dash, occupying about ten seconds, the concentration of attention is continued at its highest point throughout. The breath is held, and the whole muscular system is convulsed with supreme eft"ort, while the blood-pressure rises, much as it does in the single effort of throwing the hammer or putting the shot. If, however, the rate be reduced and the runner be allowed twenty seconds or more to cover the loo yards, the nervous tension disappears; the blood-pressure is but little affected; there is no nervous explosion, and the face remains calm and smiling.

The same exercise becomes, under these conditions, one of mild endurance; and the possibility of this transition in the same exercise from effort to endurance, or from endurance to effort, must be constantly borne in mind, much confusion having occurred by the careless use of these terms.

Feats of skill, such as juggling, are composed of isolated efforts which may be so mild in nature and so often repeated that they insensibly shade off into feats of endurance, especially when skill and practice render them automatic. The striking of a fortissimo chord on the piano is an exercise of effort. The practice of one scale for an hour would be an exercise of endurance, but the playing of the thirteenth rhapsody of Liszt, combines both effort and endurance.

The qualities cultivated by exercises of effort, whether of strength, skill, or speed, include mental concentration; the rapid response of the muscle to the will power; the ability to learn complicated coordinations and the knowledge of the easiest and most economic way of performing difficult movements. Their practice is followed by increase in the size of the muscles employed up to their physiologic limit. If carried past the limit of power, the muscles will refuse to contract, or may actually tear, and if habitually overworked, they may atrophy, and become hard and fibrous, with weak, uncertain movements. When muscles are overdeveloped, they become parasites on the vitality, which is sapped in the struggle to provide for their nourishment. Exercises of effort do not cultivate constitutional vigor to the same extent as those of endurance.

In exercises of endurance the range and variety of movement are usually much more limited. They are confined to a few well-known varieties, such as walking, running, and rowing, and though each movement is well within one's power, the total amount of muscular work is great, but as the contraction and relaxation is comparatively slow, the poisonous waste matter producing fatigue is removed from the muscles as it accumulates. In exercises of effort there is no time for the scavengers to work, fatigue of the most active muscles setting in rapidly, while in exercises of endurance they can, at least, postpone its. onset.

This class is, then, milder and more general in character. It deals with coordinations familiar from infancy. It is not necessary to concentrate the attention on every movement in walking, running, and rowing, — typical exercises of endurance, — in them the mind may be occupied with other thoughts. Breathing, which is a muscular action of endurance, is entirely automatic, but is not subject to the ordinary laws of fatigue.

The qualities cultivated by exercises of endurance are different from those required in effort. Skill is not prominent among them. Concentration is replaced by the attempt to liberate the attention, and the development of any one group of muscles is secondary to the indirect effect on the circulation and respiration in training them to remove the fatigue products of muscular contraction. '

When carried to excess, exercises of endurance are accompanied by acute constitutional exhaustion, shown in breathlessness, from which recovery is rapid; by fatigue of the whole muscular system, from which a rest of a day or two is necessary, and by the chronic or nerve fatigue known as "staleness" among trainers, from which recovery may be a matter of weeks or even months.

Fatigue appears in one of these three ways.

If the exercise be sufficiently active, the amount of waste material suddenly thrown into the circulation is greater than can be eliminated by the lungs. The breathing becomes rapid and shallow, the pulse quick and fluttering, and the runner feels a sense of constriction around the chest; his head swims and throbs and his face takes on the anxious expression so eloquently telling of the thirst for air.

The face of the breathless man is unmistakable.

The smoothness of the forehead is broken by wrinkles spreading out over the inner end of the updrawn eyebrows. The general direction of the eyebrows is just the reverse of that seen in violent effort. They are drawn upward and inward by what the French call "the muscle of pain," whose action is seen in the expression of grief, mental distress, anxiety, or bodily pain. The upper lids in

breathlessness droop and half cover the eyeball, giving a look of great lassitude to the suffering expressed by this region. The nostrils are widely dilated, and the mouth gapes, with lips retracted in the mad struggle for air. The raised upper lip adds to the look of sorrow and pain, while the down-drawn mouth angle, the tongue closely pressed against the teeth, the sunken check, and the open

Fig. 3. — The typical face of breathlessness as seen in any race above 200 yards (modeled from life by the author).

mouth, all go to increase the exhausted, haggard look so characteristic of this state, in distinction to mere bodily pain or mental suffering. The general poise of the head is backward, the chin thrust forward, and the neck strained or convulsed.

With the reestablishment of equilibrium between the production of waste and its elimination, the urgency of breathlessness fades and the runner gets what is called his "second wind." The look of distress disappears from his face. The lungs regain fresh power to expand, the head becomes clear, and the muscles act with renewed vigor and elasticity.

He can now continue running until he feels the symptoms of general fatigue.

If the pace has been slow enough, the runner may escape the acute poisoning shown by breathlessness, but sooner or later the

Fig. 4. — The typical expression of breathlessness is seen in the last nian.

products of tissue waste accumulate, the heart beats fast and weak, the nervous system is stupefied, and the muscles relax. This may, in extreme cases, end in death from overexhaustion, as has been reported in soldiers after long and forced marches.

The same condition may be studied in the face of the runner during a long distance race. After the urgency of breathlessness has passed, the expression of his face changes. The eyebrows show a slight frown, and the eyelids are heavy, as with sleep; the upper lip is still retracted from the teeth, giving a slight look of pain to the cheek, otherwise relaxed and flaccid. The mouth is half open, the jaw drops, and the lower lip hangs loosely over the parted teeth. The general expression is one of vacancy. As fatigue becomes more profound, his effort is centered in an endeavor to prevent the eyes from closing, as a consequence of the increa'sing paralysis of the muscles of the upper eyelids. The long, doubly curved wrinkles across the forehead of this mask (^Fig. 7), which shows advanced fatigue, or the last stage of exhaustion, are usually associated with the expression of surprise and astonishment, but here they illustrate the endeavor to raise the drooping eyelid. The nostrils are dilated, the lips are drawn downward and outward, the lower part of the face expressing the distress of failing respiration. The head is thrown backward and the chin thrust forward in the endeavor to balance the head without muscular effort.

Both pose and facial expression are characteristic of the last effort to fight off collapse. When this last effort is exhausted, the mmscles of expression cease to act, the circulation fails, the color becomes pale, the lips livid, and the runner falls in a faint.

The effect of this general fatigue does not usually pass away for a day or two. The body temperature rises several degrees, the patient is tired, perhaps delirious, and his night is sleepless or disturbed by troubled dreams. The urine passed is of high specific gra\'ity and contains albumin. The soreness and stiffness of the muscles and joints remain for several days, and gradually fade away as the constitution recovers its tone.

This may be said to represent the second form of general

Fig. 5. — The typical face of fatigue seen after acute breathlessness has passed off in a distance race (modeled from life by the author).

fatigue — the subacute. The third or chronic form is found in men during a course of training in which the amount of endurance required daily is more than can be regained during the periods of rest. The exhaustion that finahy comes on is slower, but more profound in its effects and more difficult to counteract, than either the acute form, corrected by a few minutes' rest, or the subacuteform, which recovers in a couple of days. In this condition the temperature becomes subnormal, the weight goes down, the skin looks pale and flabby, the muscles lose their elasticity, the eye becomes dull and listless, interest in exercise ceases, every effort becomes a burden, and the patient sits without ambition or the power to rouse himself from his lethargy.

Fig. 6. — Both faces show the typical expression of fatigue.

Recovery from chronic fatigue, or overtraining, is a matter of weeks, and since the nervous system is profoundly affected, a change of air, surroundings, and occupation, with complete muscular rest, may be necessary.

It is a well-founded rule among trainers to give long distance runners a rest of two or three days before a race to recover completely from the fatigue of the last practice run.

Long distance running has been taken as the typical exercise of endurance, but just as we found that an exercise of effort might become one of endurance, so long distance running may vary sufficiently in its pace to make it an exercise in which effort plays a more important part than endurance. In a mile race the runner will carefully regulate his pace so that the waste matter of muscular contraction can be eliminated almost as quickly as it is produced, and his resources husbanded for the moment when experience teaches him he can exert all his latent power in the final spurt. This is so timed that the finish line will find him completely breathless and exhausted.

A mile race is, then, an exercise of endurance throughout most of the distance, and at the finish an exercise of effort, the change showing by the expression of the face. It is in finding out the pace and the point at which effort must begin that the genius of the true athlete is seen or the skill of the trainer is shown.

Exercises of endurance, then, have much more profound influence on the general system than exercises of eft'ort.

In the typical exercises of effort, such as feats of strength or skill, the resulting fatigue is principally a local one, and includes soreness of the muscles most strongly in action, which refuse to function when the effort becomes too great.

In exercises of endurance the constitutional fatigue is greater and powerfully affects the heart, lungs, general muscular and nervous systems.

Passive exercise finds its widest field of usefulness in conditions of fatigue, where the elimination of waste matter must be assisted.

Fig. 7. — The typical face of exhaustion seen just before collapse in a distance race (modeled from life by the author).

and where nutrition of the part is impaired or destroyed. The patient remains inert and is acted upon by the operator oi his mechanical substitute. Muscles can be improved in size, tone, and nutrition, ligaments stretched and strengthened, the general circulation quickened, and overloaded veins made to disgorge

Fig. 8. — The finish of a race, showing effort on the right, exhaustion in the center, and

collapse on the left.

their blood. The digestive tract can be stimulated to more active habits, and overwrought nerves soothed and relieved of their hypersensibility.

The full and detailed description of the typical movements of massage will, however, require a chapter to itself.

Chapter II The Physiology Of Exercise

Bodily movements affect profoundly the motor apparatus, the vessels which supply it with nourishment in the form of blood and lymph, the storehouses of nutrition in the abdomen, and the controlling and directing mechanism of brain and nerve.

The impulse to contract a muscle begins at its motor center in the brain or spinal cord^ and is carried to it by a motor nerve. Each muscle-cell shortens and thickens, scattering some of its substance into the lymph-space encircling it, and absorbing food consisting of carbohydrates and oxygen from this surrounding plasma.

By repeated contraction the cells increase in size and number, the perimysium is strengthened, the fibrous wall surrounding the bundle of cells is invigorated, and fresh power is imparted to the sheath inclosing the entire muscle. The result is an increase in bulk, in strength, and in elasticity. The tone of a healthy muscle keeps it in slight contraction even when at rest, so that antagonistic groups retain the inactive limb in normal position, but constant overaction and strengthening of one group of muscles increases this normal tension until the accustomed pose becomes habitual, as in the curved fingers or bent arms of the oarsman or weight-lifter.

During contraction there may be actual rupture of the cellwalls and exudation of blood and lymph. This is one of the two causes of muscle soreness found after severe straining exercise. The other cause is the presence of irritating waste matter imperfectly carried off by the blood-stream. This process of elimination is improved if the muscle be kept warm, but as muscular action generates heat, this usually regulates itself. When the liml) is cold or inactive, the heat of the muscles must be enkindled by preliminary massage and light exercise l^efore undertaking with safety any severe athletic test. The lack of this precaution in cold weather is the cause of most ruptured muscles and tendon strains. Galen recognized this fact in the second century and writes: "If any one immediately after undressing proceed to the more violent movements before he has softened the whole body and thinned the excretions and opened the pores, he incurs the danger of breaking or spraining some of the solid parts, . . . but if beforehand you gradually warm and soften the solids and thin the fluids, and expand the pores, the person exercising will run no danger of breaking any part."

The overproduction of heat is fairly well equalized by evaporation through the skin and lungs, although general massage is followed by a slight rise in temperature, and there is always some fever attending and following a long distance race.

The effects of the three kinds of exercise described in the previous chapter on the structure and behavior of the muscle vary widely. Single and complete contraction, however mild the resistance, improves the nutrition if frequently repeated, as shown by an increase in size and efficiency. When, however, the tension is habitually excessive, minute ruptures occur in its substance and sheath, fibrous deposits are formed, and the muscle itself becomes shortened, hard, and inelastic. Even when at rest, the specialist on the horizontal bar wall show the rounded shoulders, the bent arms, and curved fingers developed by too exclusive devotion to this exercise.

The number of muscles involved in a simple movement multiplies with the intensity of the effort. The trial of grasping power by the hand dynamometer is designed to test the flexors of the hand and forearm, but in the strife for additional force, muscular contraction spreads to the arm and shoulder and throughout the entire muscular system until its intensity is expressed by the face. If, however, skill is an important factor in the exercise, the emphasis on alacrity and accurate control cultivates in the muscle economy of effort and promptness in responding to the will. In other words, the latent period is shortened.

In exercises of endurance each movement is comparatively mild, and there is less tendency to shortening and stiffening of the muscle so frequently found after extreme effort. Development is general rather than local, and long distance runners are not noted for the thickness of their calves.

General nutrition is best improved by the rhythmic self-massage of movement. " Every muscle is a throbbing heart, squeezing its vessels empty while in motion and relaxing to allow them to fill up anew" (Weir Mitchell). The element of skill does not play an important part in such habitual or &,utomatic movements as walking or running, so that their value in its promotion is comparatively slight.

Passive exercise improves the nourishment of the muscle-cell by forcing out the products of fatigue and keeping it bathed in a constantly renewed stream of arterial blood. This alone is sufficient to prevent wasting of substance in conditions where active movements are impossible, but it has little power to modify m.uscular strength or control.

It can be demonstrated that the amount of blood in the muscle, as in the heart, varies with its contraction and relaxation.

Mosso, of Turin, found that an arm inclosed in a water plethysmograph (Fig. 9) diminished in volume on contracting the flexors and immediately increased above its original volume when they were relaxed. He also found an increase in the amplitude of the pulsations of the whole arm during and after the contraction of the flexors. These experiments have been confirmed by Sir Lauder Brunton and other observers, and it may be considered as conclusively proved that the blood-vessels are substantially enlarged in the active muscle after contraction, and during the contraction itself the interchange of products between blood and muscle is also accelerated. Xot only is this true, but the actual nourishing power of the blood is augmented by this heightened activity.

It has been proved by Hawk, in his interesting experiments on the Ijlood-count of athletes in training' at the University of Pennsylvania, that various forms of active muscular exercise produce an average increase of 16.8 per cent, in the num1)cr of red corpiis-

^ " Am. Journal of Physiology," \'ol. x., Xo. viii.

cles, the greatest increase being 26.7 per cent, in a subject who had played water polo for a period of three minutes, the lowest increase being noticed after long runs and bicycling. When exercise is long continued, the rate of increase lessens and the number may even decrease in violent exercise sufficiently prolonged. This, he explains, is due to the passage into the circulating blood of a large number of cells lying inactive in various parts of the body until they are brought into service by the muscular exercise.

Fig. 9. — A schematic diagram of Mosso's pleth^/smograph for the arms : a. The glass cylinder for the arm, with rubber sleeve and two tubulatures for filling with warm water; s, the spiral spring swinging the test-tube, .'. The spring is so calibrated that the level of the liquid in the test-tube above the arm remains unchanged as the tube is filled and emptied. The movements of the tube are recorded on a drum by the writing point, p. (Howell).

John K. Mitchell gives the same explanation^ for a similar, increase found after massage. This would also account for the fact that they decrease after prolonged exercise in which this reserve, as well as the original circulating proportion, is. consumed in the furnace of muscular action. The specific gravity of the blood is heightened by evaporation from the lungs and this tends to mask the continual destruction of red cells in long tests of