Another indication for bodily rest, which should by the way always be accompanied by mental rest, is a weak heart action, whether this he due to disturbances of compensation through cardiac failure, to paraly sis after scarlet fever or diphtheria, to the weakened conditions secondary to influenza, or to other causes, and this safeguard should be continued so long as exertion causes the heart to heat much more rapidly or irregu larly. A final indication for prolonged rest is to be found in those diseases of the nervous system which are accompanied by mental or physical unrest (excitement, fear, marked ties, and chorea). Every rest cure must be terminated at the proper time, lest the patient become debilitated.
Even during the course of the treatment, the muscular tone may be somewhat stimulated by means of dry rubs, sponges, alcohol rubs, or light stroking massage, which must be very carefully performed in car diac disease. To this may he added somewhat later muscular exercise in bed. The muscle exercises may be either active or passive. They must encourage respiration by being performed rhythmically, and syn chronously with deep inspiration and expiration.
Massage is next to be tried with the passive muscle exercises. Strong kneading of the muscles is, as a general thing, to be avoided; it must not excite the patient or be followed by sleeplessness. General massage is next employed for a time, but its use, at the beginning, must be restricted to the extremities. General massage is also useful in the muscular weakness of flabby children and in the muscular relaxation of rickets. Its sphere of usefulness is, upon the whole, not a large one, since active exercise in the open air, under favorable conditions, is very much better, as we will show later. When this cannot be practiced, however, as in the muscular atrophies following diseases of the nervous massage must take its place. The massage of certain groups of muscles is indicated in orthopedic cases and in the treatment of chronic constipation. Abdominal massage, which may be practiced in various ways, hut always methodically (either by the physician or by the nurse), must of course never he used in acute inflammatory condi tions of the abdomen. Older children may he able to massage themselves by using an iron ball with a knitted or leather cover and weighing from 2 to 3 kg. (3 to 5 lb.). The patient lies upon the back, with the knees drawn up, and the ball is rolled around the umbilicus in the direction in which the hands of it cluck move. This should he done in the morn ing before food has been taken. and he continued for at least ten minutes.
Electrical treatment is also to be considered. This is of very little use in childhood, excepting as it acts through suggestion, and in paraly sis of muscles.
Passive movements particularly are to be practiced in such a way that they will be dichronous, and be accompanied by deep inspiration and expiration. For example, a position is taken behind the patient, who is seated on a chair, or if bedridden upon the edge of the bed: the elbows are grasped and the arms arc raised from the side, or rolled in the shoulder joint, or carried horizontally forward and then backward, without, however, allowing the patient to participate in the effort.
The transition to active movements is made through the use of resisted movements, in which the attempts by the patient at flexion and ex tension of the extremities and body are resisted by a more or less powerful pressure in the opposite direction by the hand of the operator. A skilful graduation of the pressure can call forth any degree of muscu lar contraction, and by gradually inereasihg the pressure the functional ability of the muscles is progressively improved. Passive and resisted movements may also be carried out by means of special apparatus. By this method it is possible to graduate minutely the exercise for each group of muscles. The active exercises are the more natural. however.
During early childhood, from about the second to the sixth year, there exists an innate tendency to exceedingly active exercise, which even in future years, at least in males, manifests itself in a strong desire for suitable exercise within certain limits. Different organic diseases may interfere with exercise, especially when they are accompanied by dyspncea; nervous diseases may also act similarly. Of the latter, lieu rasthenia„ with its hypersensitiveness to bodily sensations, takes the lead from a therapeutic standpoint; but, as will be shown below, the combined physical method of treatment may readily overcome the obstacles interposed by mental influences.
As early as the fourth year, but principally during the school years physical training is added to the natural exercise. This has a most remarkable influence upon the development of the powers of observa tion, the will, and the muscular control, and improves the capacity and strength of the muscles, particularly those of respiration. As we will not here consider orthopaedic exercises, or exercises for simple hygienic purposes, we need hardly take into consideration exercise by means of apparatus, but may simply direct attention to those which can be per formed without any apparatus excepting perhaps the horizontal bar. These are to be performed in the fresh air, in as light clothing as possi ble, and may even be carried out while taking an air bath (see below). Marked acceleration of the pulse and overheating must not be permitted to occur, where exercise is ordered with a purpose. For school children, swimming in summer and skating in winter are also to he encouraged; and in later youth various sports, such as tennis and bicycling. The latter is to be used moderately by weakly or nervous subjects, care being taken that they do not overexert themselves; in other words, they should not be permitted to take long journeys without a. prede termined limit, and then only while maintaining a. correct position upon a saddle properly shaped and adjusted.