In diseases of the Central Nervous System massage and gymnastics play nowadays important parts. The brilliant results obtained by Frenkel's compensatory gymnastics in cases of ataxy with tabes have made it the duty of every doctor not to neglect that part of the treatment, and have also stimulated interest in systematic exercise for all disturbances of the motor nervous system.

In massage for diseases of the central nervous system the muscle centres are acted upon through the peripheral nerves with which they are in physiological connection. Long ago, however, it was found that if the nervous centres could not be directly treated they could in many cases be strongly affected by vibrations over the cranium or spine.

Treatment by vibration in diseases of the central nervous system is an old method of treatment. Abbe St. Pierre invented in 1734 his "tremoussoir" or "fauteuil de poste" for sedentary people; it was widely used and praised as having a beneficial effect on the nervous system, and even won the approval of the hypercritical Voltaire. In the present day there are many forms of vibratory apparatus,which act on diseases of the central nervous system. Among the Zander apparatus since 1868 there is a semicircular padded metal plate which vibrates from side to side, and is placed over the cranium and comes into contact with the head on either side alternately. This, in my opinion, is the best of all vibratory apparatus used for insomnia. In Charcot's clinic in La Salpetriere in Paris, in 1878, Vigouroux performed vibrations by means of an enormous tuning-fork and a sounding-box; by these means he succeeded in removing hemi-anaesthesia and contracture in hysterical patients and relieving the shooting pains of tabes dorsalis. Boudet in Paris, in 1880, worked by means of a tuning-fork driven by electric power, the vibrations of which were carried to a sounding-box of wood and thence to a small point or plate supported by a metal stem; he thereby produced local anaesthesia and analgesia and cured neuralgia. In Italy Morselli and Buccola used a similar apparatus for melancholia, insomnia, and neuralgia. About this time, too, in England Dr. Mortimer Gran* ville used vibration therapy for nervous and other disorders by means of an apparatus for percussion. I must also draw attention to two French apparatus, both of which were used in Charcot's clinic in La Salpetriere in Paris, and which affected the cerebro-spinal centres by means of vibrations, one by vibrations on the head, the other by setting the whole body in vibration. One was "le casque vibrant,' invented by Charcot's chef de clinique Dr. Gilles de la Tourette, and consists of a steel hood, which by means of a simple contrivance can be made to lit any head, and which is set in very regular vibration at the top by a little electric motor (about 6,000 per minute); the motor is quite isolated from the patient's head, and the treatment is therefore absolutely mechanical. I may add that "le casque vibrant ' is used in treatments of about ten minutes" duration for neuralgia and migraine, especially for insomnia, as well as for the whole series of (cerebral and spinal) neurasthenic symptoms, and for cases of melancholia. The other apparatus, the "fauteuil trepidant," is an ordinary easy-chair which is set in vibration by manual means or by gas, electricity, water, or compressed air; it is used in treatments of twenty to thirty minutes and given to patients suffering from paralysis agitans; it was invented by Charcot, who had observed the good effect of railway journeys on such patients. This apparatus also has its representative among Zander's machines, where there is a vibrating board on which the patient can sit, but this is more generally used to give vibrations over the legs. Quite lately M. Herz has invented a vibrating bed.

In Psychoses, also, vibrations have been applied to the central nervous system (through the cranium), and have often given positive results. In his lectures (see "Iconographie de la Sal-petriere": Paris, 1892) Charcot speaks of the probability of the beneficial effects of vibrations in such disorders; he also speaks of an instance of melancholia which seems to have been cut short by this treatment, and which, until the vibrations were begun, had shown no signs of improvement.

For local vibrations excellent apparatus exists which can be placed on the forehead, on the occipital protuberance, and on the sides of the head. Several minutes' vibration of this kind gave very good results in insomnia. Experience has shown that manual vibrations act beneficially in neurasthenic insomnia; in emotional psychoses they are sometimes beneficial, sometimes harmful; in cases of auditory hallucinations they are harmful.

We have also learnt that static pressure on the motor nerves removes spasms, e.g. in facial and spinal accessory cramp, and Frey has noticed that saltatory symptoms can be made to cease by pressure on the corresponding muscles.

It is worth remarking that the wonderfully good results of Frenkel's exercises for tabes must not make us allow them entirely to take the place of massage for this or other diseases of the central nervous system. Even before Frenkel's time very good results, especially in tabes, were obtained chiefly by massage in Stockholm, especially at the Orthopaedic Institute. All four extremities were treated by effleurage, petrissage, and tapotement with vibrations over the nerves corresponding to girdle sensations or other sensory disturbances, over the spinal cord and over the bladder; in short, . a strong general massage was given, specially adapted to the case. It was surprising to an onlooker to see the great amount of mechanical work which each patient received while in the hands of the doctor or an assistant during a full hour's treatment with very little pause.

As soon as motor symptoms appear gymnastic treatment is given, and all methods are used which facilitate movement in cases of paresis (see pp. 129 - 131). I must here remind my readers of the value of the so-called kineto-therapeutic baths, which are little known in Sweden, and the use of which I have come to know and appreciate since infantile paralysis has become so common.

Massage and gymnastics are therefore a legitimate and indeed an absolutely obligatory method of treating diseases of the central nervous system, in acute cases as soon as the acute process has ceased, in chronic cases during the whole, or at least the greater part, of the course of the illness.

In Sweden similar treatment has been used with more or less good results in shock, trauma, and haemorrhage; in chronic myelitis and compression myelitis; in tabes dor sails, hereditary ataxy, and multiple cerebrospinal sclerosis; in amyotrophic lateral sclerosis; in progressive muscular atrophy and pseudo-hypertrophic muscular atrophy; in paralysis after acute anterior poliomyelitis; in toxic paralysis, very often in the common lead paralysis; in co-ordination trade neuroses; in chorea, and in hysterical affections.

It is quite unnecessary, after all that has already been said in the chapter on the Effects of Massage and Gymnastics and in this chapter, to give in detail the kind of treatment and the result to be expected in every kind of illness. Both massage and gymnastics are used on the above principles for the various functional disturbances, and each one may easily devise his own method. Here I purposely speak only of the treatment for tabes, chorea, coordination trade neuroses and hysteria, and shall then describe Weir-Mitchell's cure by rest, massage, and mud baths. *****

Tabes Dorsalis, (syphilitic) sclerosis in the posterior horns of the spinal cord, is treated now more or less all over the world by massage, and especially by gymnastics.

Frenkel's method of gymnastics has been equipped with extensive apparatus. In order to give gymnastics in this way expensively-fitted institutions are required - for example, such as those found at La Salpetriere in Paris and Frenkel's own institution at Freihof in Heiden, as well as the Moabite Hospital and Professor Leyden's Hospital in Berlin. The private practitioner and the private patient can only on exceptional occasions make use of similar establishments, for the description of which I refer my readers to the many special works on the subject. It is satisfactory to know that this elaborate apparatus can be easily dispensed with and that Frenkel's method can be effectively used by means of much simpler and cheaper appliances.

The chief object of compensatory gymnastics is to replace by some other form of sensation, especially the sense of sight, the sensation which has been lost by sclerosis of the posterior horns of the spinal cord, and to improve and train the centres of co-ordination and movement to perform their functions with limited sensation.

The exercises which are used in these cases are performed slowly, and the patient tries especially to control them by the antagonists of the contracted muscles; compensatory gymnastics are therefore fundamentally self-resisted exercises (see pp. 131, 132).

In advanced cases attention must be paid to the hypotonus of the patient, to the diminished physiological resistance, and to the faulty carriage of the body which is sure to follow; for this purpose there are several different pieces of apparatus. In very advanced cases, where the patient finds it difficult to hold himself up, Frenkel has constructed a chest girdle provided with two handles on each side, one in front and one behind, by which assistants support the patient; necessary support can also be given by a "walking-chair," a hand-rail, or walking-sticks.

In all these movements the doctor must carefully decide the amount and character of the exercises, and never allow the patient to be fatigued. The patient is unable to decide this, for he will more or less have lost the sense of fatigue, which in normal persons is the intimation of muscular fatigue.

Exercises for the lower extremities are done in lying, sitting, or standing position, or walking.

If we make a choice of exercises from Frenkel's, Goldscheider's and Jacob's movements, we can compile the following gymnastic scheme, which requires very little apparatus, can be carried out in the patient's home, and is given with very satisfactory results. Those who wish for further details on the subject are referred to special works.