All cases of sprain, simple or complicated, except, of course, those where there exists a fracture of the joints (and we have seen that even this is not now regarded as a contraindication), are tributary to massage. The beneficial effects are the more speedy and the more certain the sooner massage is applied after the accident, and you will often see patients who at first could not stand on their feet get up and walk, and even return to their homes on foot, after their first séance of massage.

But it is necessary to be exact in the diagnosis, and this it is that explains the reason of the successes and the failures of the bonesetters, who apply massage to all the traumatisms of the joints, whether these pertain to sprain or to white swelling. In the case of sprain, marvellous results are easily obtained, while in white swelling only disastrous consequences would ensue from massage.

You ought, then, gentlemen, to understand well all the manœuvres of massage in sprains. All that have been counselled thus far may be summed up in three processes, those of Lebatard, of Gerard, and of Magne.

In the process of Lebatard, the masseur seizes the heel of the extremity which is the seat of the sprain with the palm of the opposite hand; then he makes with the foot a seesaw motion back and forth, while exercising a strong traction on the tendo-Achillis. In this manipulation the thumb is made to grasp as far as possible the tibio-tarsal swelling, while the endeavor is made to force behind the external malleolus all the swollen parts. The opposite hand executes similar movements over the internal malleolus; then, when the malleoli have recovered their natural form, the fingers seek by pressures over the tendoAchillis to free that tendon.

Gerard's method is less harsh than that of Lebatard. It consists in light rubbings (effleurements) with the tips of the fingers. After ten or fifteen minutes the operator passes to the second stage, which comprehends a kneading of the peri-malleolar parts; this is made from below upward, from the tips of the toes to the upper third of the tibia. Then the massage is completed by a few flexions and extensions of the joint.

Magne's process, adopted by Estradère, is intermediary between the other two. The operator commences by frictions, the intensity of which is gradually augmented. At the end of thirty or forty minutes, he exercises the joint after the manner of Lebatard, then he finishes by a massage of fifteen or

twenty minutes. The total duration of the operation is nearly two hours.

As you see, gentlemen, the massage of sprains is very simple, demanding of the physician first an accurate diagnosis, then energy, then patience.

Busch, who in Ziemssen's Hand-book has given a good monograph on massage, considers that in sprains these manipulations fulfil the three following ends: First, they restore the parts to their natural situation, and in this connection he refers to the practice of one of our surgeons, Ravaton, who, in cases of sprain, has two stout men pull apart the articular surfaces, while the hands of the surgeon are clasped tightly around the joint thus stretched. The second effect of massage is to lessen and abate the muscular spasm which always accompanies the articular distortion. Here kneadings of the muscles act the most effectually in antagonizing this spasmodic state. The third result obtained by massage consists in the disappearance of the bloodeffusion which attends sprains; the absorption and removal of this effusion is promoted by the rubbings, which are made from the extremity of the member to its base.

As for the results thus far gained, statistics are most favorable, and in those which have been published by Mullier and Moller, it appears that while immobilization and ice will bring about the cure of a sprain in an average of twenty-five days, massage well performed will accomplish this result in an average of nine days.

In the Prussian army, where massage is obligatory in a certain number of affections, and, in particular, in sprains, the military surgeons, in their half-yearly reports, do not fail to communicate the results obtained by this method. By referring to the reports of Starke, Gassner, Brurberger, Gerst, and Korner, you will see that the average duration of the disability entailed by sprains, where massage has not been employed, is 27.3 days, and where massage has been used 8.9 days, so that you see there is a difference of 14.8 days in favor of the treatment of sprains by massage. It is to be wished that the same practice might be obligatory on the military surgeons of our army. I ought here to remark, however, that my friend and colleague, Marc Sée, considers compression made with an elastic bandage, in the case of sprains, superior in its results to massage.*

* Marc Sée, "On Sprain and its Treatment." Paris, 1884.

4. I come now to the medical applications of massage. These are very numerous, and we will, if you please, divide them into several groups. I will speak, first, of massage in the treatment of pain, then in articular and muscular affections, then in neuroses, and, lastly, in certain visceral affections.

As I have before told you, it is by an instinctive movement that man seeks to relieve pain by frictions, and I have often seen patients in the agonies of tic douleureux rub the skin till abrasion and bleeding were produced. Experts have given regularity and system to these practices, and what I have to say on this head shall pertain particularly to sciatica and migraine.

It is Schreiber* who has given us the most precise rules as to the treatment of sciatica by massage. The treatment of sciatica, according to Schreiber, consists in massage, the application of certain apparatuses, and in passive

The frame is a very simple affair, and is composed of two uprights pierced with holes, which enable one to elevate to variable heights a horizontal bar (g, h). (See Fig. 1.) As for the mechanical bed (Fig. 2), it is also of Schreiber's invention, and is of simple construction. It is composed, as you see, of different segments, which are raised or lowered at will by means of ratchets. The patient is placed on the bed, as is shown in Fig. 3. As for the joists, they are one metre long,

* See his book on "Massage," recently published by Lea, Philadelphia.

six centimetres thick, and twelve centimetres wide.

This is the way these means are utilized, along with massage, in the treatment of sciatica. I shall not follow Schreiber in the enumeration of all the manœuvres, day by day up to the thirty-second day, which are prescribed by that authority, but shall only give a rapid sketch of his method.

The first day the patient is placed before the frame, and the horizontal wooden bar being placed as low as possible in the two uprights, by adjusting the pins (k), the patient is directed to extend the foot of the affected limb upon the transverse bar, holding on to the two uprights by his hands. This manœuvre is repeated ten times.

Then the patient is placed on the mechanical bed, as is seen in Fig. 3, and passive movements are executed, which consist in flexing the thighs on the body and elevating the leg on the thigh; these movements are repeated twenty times. Lastly, a gentle massage is practised, which consists the first day in simple light rubbings over the painful points.

The second day these manœuvres are repeated, especial attention being given to massage, and kneading of the muscles is then begun. Passive movements also are performed; the thigh is moved back and forth from the middle line.

Then the following days the movements are progressively increased, and the horizontal bar of the frame is gradually raised by putting it into the higher sockets, so that the patient is obliged every day to attain with the foot a greater height.

At the end of the first week the exercises with the little posts are commenced. These are placed on the ground at regular intervals (like nine-pins), and the patient is made to walk between them without hitting them with his feet.

Lastly, the passive movements are performed by rotating the affected thigh in its joint.

Such is the mechanotherapy and the massotherapy treatment of Schreiber. It is, as you see, somewhat complicated and lengthy, and is only applicable to cases of sciatica which are stubborn,-i.e., to those which have resisted punctiform cauterizations and the methyl spray. In such cases as these I cannot too much recommend Schreiber's method.

This practice of massage is applicable to all the other neuralgias, but the manœuvres are variable, according to the seat of pain, and among these painful affections I must

the head, just as if one was playing on a piano. A certain dexterity is required in executing this manœuvre, which, if we may trust the trials made by Romberg, by Dubois-Reymond, and especially by Dr. Weiss, gives excellent results.

Lucas Pardington has, moreover, quite recently taken up the subject of treatment of migraine by massage, and he has reported a case of a man, 26 years of age, suffering from hemicrania of grave form and rebellious to all the means of treatment, which was

ous as it is to practise massage on a joint which is the seat of an intense acute inflammation, there is no disputing the advantage which such massage can confer on joints when the acute symptoms have disappeared, and you can see at any time in our hospital wards the remarkable results obtained from massage by our clinical assistant, M'lle. Chappat, in the treatment of the sequelæ of rheumatism, generally so long and painful. Here the action of massage is twofold. It not only restores movement to the joint, but it promotes reso

M

cured in three days by séances of massage of twenty minutes' duration made over all points of the head and neck which were affected.*

As for the articular affections, it may be affirmed that all kinds of stiff joints, chronic

lution and disappearance of engorgements and periarticular adhesions.

The manipulations vary according to the joints affected, but all have this end,-gradually to restore the movements of the joint on the one hand, and the natural form of the

It is the same with the muscular affections,

-atrophy and contracture. In these cases massage is superior to gymnastics.

In his interesting monograph on massage, William Murrell calls particular attention to the benefits which may be derived from massage in infantile paralysis, locomotor ataxia, and in writer's cramp.

Wolf, of Frankfort-on-the-Main, was the first to lay down the rules of treatment of writer's cramp by massage. Wolf is not a physician, but a professor of gymnastics. The method which he urges consists of massage and gymnastic manœuvres. His favorite massage movements are principally frictions and digital taps. The gymnastics which he advises are both active and passive, the former consisting in sudden movements, which the patients execute with the hands, which are now opened and now shut, and which are kept up for half an hour; these exercises are repeated three times a day. The passive movements consist in the forced distention, or rather elongation, of the muscles of the fore-arm. This elongation is done by the patient himself, who repeats it three or four hundred times a day. If we may believe Romain Vigouroux, * this treatment causes writer's cramp to disappear in a fortnight.

I will add that for the symptom cramp, whatever may be its cause, massage is a sovereign remedy, and you should here employ principally kneading of the muscles and the strokes or taps (tapotement).

Paralysis agitans is also believed to be amenable to treatment by massage, and Berbès has recently reported to the Society of Therapeutics the favorable results which he has obtained by this means in a case of Parkinson's disease.t

As for the neuroses, I shall not repeat what I have said à propos of the treatment of chorea by gymnastics, where, in truth, massage is oftener employed than gymnastics properly so called, but I must call your especial attention to massage in hysteria, because serving as the basis of a kind of treatment of this disease which has become very popular of late years under the name of S. Weir Mitchell's method. This mode of treatment is complex, and demands for its execution the isolation of the patient, absolute repose, and the employment of massage and electricity.

Dr. S. Weir Mitchell begins by completely

isolating his hysterical patients from their family and usual surroundings, and putting them under the care of a trained nurse, who never leaves them; then he subjects them to absolute repose and a special diet system, of which milk and eggs form the basis. Then he insists on the application of general massage, and sometimes of electricity, which plays, however, but a secondary rôle in the treatment, as the movements produced thereby only serve to combat the disastrous effects of immobility. This treatment has had but few advocates in France, and it is hardly applicable except to extreme cases of hysteria. Nothing shows that it is superior to the treatment which we employ in such cases, isolation, hydrotherapy, and exercise in the open air. I shall, however, return to all these points in one of my future lectures on hydrotherapy.

It remains for me to say a few words concerning massage in general affections. In diseases of the heart, massage will render you service in combating edema, and the same may be said of edema due to renal affections; and I remember to have seen a remarkable example of this. The patient was the wife of a medical confrère, who was suffering from albuminous nephritis, with considerable anasarca of the lower limbs, which doomed her to absolute rest. Massage removed the ædema, which did not return, although the quantity of albumen in the urine remained unchanged.

Here the effects of massage are twofold. It acts, first of all, locally, and favors the resorption of effused liquids; then it has a general action, promoting nutrition, augmenting the excretion of urea, and thus combating one of the effects of chronic alterations of the kidneys.

Furthermore, I showed you, while speaking of the physiological action of massage, that the practice of abdominal massage notably augments the excretion of urine. This is an effect which ought to be taken account of in explaining the favorable effects of massage in cardiac and renal affections.

Lastly, in abdominal affections, constipation, and dilatation of the stomach, massage has been found to give excellent results. When, in fact, you study the physiological observations of Chpolianski and of Gopadze, you see that by massage the assimilative functions of the digestive tube are promoted, and the passage of the alimentary bolus is favored. Clinical observations give support to the facts testified to by physiology.

As for constipation, everybody is agreed in acknowledging the good results obtained by massage. Berne,* who has so urged the importance of abdominal massage, recommends the following mode of procedure: After having kneaded the abdominal teguments, then the abdominal muscles, the operator makes gentle pressure over the cæcal region with the palmar extremities of the last four fingers; then, with the closed fists, he performs massage over the whole extent of the colon. Berne insists that this massage shall be both very gentle and very deep. He recommends, moreover, that the patient should be made to urinate before massage, and that careful examination should be made to see if there be any tumors in the abdomen, or any calculus in the gall-bladder. The length of each séance should be fifteen or twenty minutes. Besides insisting on the mechanical action of massage, Berne makes great account of the property which these exercises possess in promoting the secretion of bile. Hence he advises to associate with the abovementioned manœuvres gentle pressures over the gall-bladder.

As for the application of massage to the affections of the stomach, and in particular to dilatation of the stomach, massage in these cases gives excellent results. For more than a month past you have seen in our hospital wards Dr. Hirschberg practise massage on the greater part of our patients who are suffering from dilatation of the stomach. You have been enabled to witness the marked benefits which these patients have derived therefrom; their digestion is improved, their weight is augmented, the clapotement and all the distressing symptoms are alleviated. It is, then, a practice which you ought to resort to in such cases.

Such are, rapidly summarized, the hints that I wish to give you respecting massage. I believe that these suggestions will be of value to you, and that you will be able to turn them to account in your future practice. For my part I have never ceased to felicitate myself on the use which I have made of massage.

In the next lecture we will undertake the study of one of the most powerful agents of hygienic therapeutics, often put in practice along with gymnastics and massotherapy: I refer to hydrotherapy.

WE

DITANA DIGITIFOLIA.

BY H. H. RUSBY, M.D., DETROIT, MICH.

are told that in 1870 Prof. Westore Giurleo received from a friend, an Italian chemist, then residing in Mexico, the flowers of a plant whose habitat was said to be Virginia. On account of the peculiar construction of the leaf the plant was called Ditana digitifolia. Experiment with the drug, with reference to its therapeutic value, disclosed the fact that it possessed valuable galactagogue properties, as by its internal "application" the secretion of the milk could be perceptibly increased. Thorough investigation could not be made on account of the scarcity of material at hand. Prof. Giurleo, however, read a paper on the subject of this plant and its properties, under the name of Ditana digitifolia, before the Italian Medical Congress of Perugia, by which means he succeeded in getting the drug before the reputable physicians of Europe, and secured notices in the medical press, the name Ditana digitifolia always being used. An abstract of his paper was printed in Il Morgagni, parte 11, 44, 1885. This article afterwards reappeared in the Deutsche Medizinal Zeitung, and was from time to time noticed in many other journals. In this country it was briefly referred to in the THERAPEUTIC GAZETTE, The Chicago Med. News, and the N. Y. Med. Journal. The Med. News says, "The professor has apparently been misled, as no one but himself has been able to find the plant." The Med. Journal considers that Ditana digitifolia is a synonyme for Rhamnus alaternus L.

Mr. Thomas Christy desiring to obtain supplies of the drug, wrote to his agent in Mexico, enclosing a drawing of the plant, copied from an advertisement of a patent medicine claiming to be made therefrom. His agent replied that he had been unable to obtain any information in regard to it, but that, judging from the drawing, it belonged in the family Onagraceæ, the flowers having the form of Zauschneria. Mr. Christy then applied directly to Giurleo, but his communication was unnoticed. Messrs. Parke, Davis & Co., taking the investigation in hand, after vainly exhausting every other source of possible information, wrote to Prof. Giurleo, urging that

ing this name. In reply they received a supply of quack advertisements, with a label printed in four languages, in which Giurleo sets forth that the remarkable remedy "Ga