But to restore function volitional effort on the part of the patient is the one and only final curative agent, and herein lies the chief disadvantage of all Zander apparatus. It is liable to convey to the patient the idea that the apparatus is going to effect the cure, and that all he has got to do is to allow the machine to restore him. Used in this spirit, not only Zander apparatus, but all other restorative means, are doomed to failure. Yet the Zander installation, beyond all others, it seems to me, tends to engender this spirit. I know it is not intended to do so, but the liability remains none the less. It is inevitable that, among unintelligent patients, the more elaborate is the installation the more will the patient expect the apparatus to accomplish for him, and the less will he suppose it is necessary to do for himself.

The last reason why I do not personally make more use of Zander apparatus is that it is perhaps the most difficult type of instrument to superintend while in use. It is almost impossible to judge how far the patient is really exerting his volitional power to secure the effect desired. In other words, it seems to set a premium, as it were, on "cheating" - be it voluntary or involuntary - on the part of the patient. The patient who blatantly sits and reads his paper while an apparatus does something to his lower limb cannot expect to derive much restoration of function. But, even putting aside such an extreme example as this, without full explanation (not of what the apparatus can do for the patient, but of how the patient is to use the apparatus for himself), the benefit bestowed cannot reach a very high level.

Contrasting the use of other forms of apparatus, the weight and pulley, again, admits of a large element of "cheating"; and, unless adequate instruction is given, it is comparatively easy for a patient to perform certain movements without calling into play the muscles they were designed to strengthen. But this fault is easy to detect, even by superficial observation, while few patients would imagine that the use of this particular type of apparatus could do much for them unless they make serious voluntary effort themselves. The very nature of Swedish apparatus precludes all idea that it will, per se, accomplish anything for the patient at all, and its use absolutely ensures voluntary effort in the direction desired - provided, once more, that instruction is adequate.

At St. Thomas' I have frequently made trial of a "universal" pendulum apparatus, but more and more I discard its use for the reasons given above. Used keenly and intelligently, it can achieve its end, but no more readily than, if as well as, the other means at our disposal. Were, however, trained help lacking, I can quite imagine using it more freely; but it would be done with a feeling that I was hoping for the best that some of my patients might have the intelligence to use it properly, and a conviction that those who did so would be in a minority.

The question of expense of a Zander equipment must also be borne in mind, and I would conclude this subject by quoting from Colonel H. E. Deane's book, Gymnastic Treatment for Joint and Muscle Disabilities.1 In this Colonel Carless writes, a propos of a visit to the Grand Palais: "Whilst one appreciates the skill and ingenuity here manifest, the same feelings are again produced, viz., that the work is being done for and not by the man." Colonel Deane adds to this, as a further disadvantage, that "the use of machines is stereotyped and monotonous." The earlier pages of this book are largely devoted to the essential desirability, when attempting to restore function, of co-ordinating the activities of an injured limb to all those that are uninjured. The value of double arm or leg work and of general exercise for the whole body is emphasised again and again - a procedure well-nigh impossible with most Zander apparatus. "Indian clubs," he claims, later, "are superior to any machine" - and I fully agree; as also with his opinion that "it is pathetic to see men . . . using a pulley machine or having their limbs moved by a mechanical device, reading their letters and newspapers." After speaking of the use of assistance in various gymnastic exercises he adds: "This is in striking contrast to the deadening effect of any mechanically devised assistance which is unvarying in its operation, and affords no indication as to how much the man is doing and how much the machine."

In sum, then, the disadvantages of Zander apparatus seem to me to be: -

(i.) It is expensive. (ii.) It can accomplish nothing which cannot be effected at least equally well by other means. (iii.) It presents a form of treatment that is least calculated to ensure volitional effort on the part of the patient. (iv.) It attempts to restore function of an individual joint or part by treatment confined to that joint or part alone, instead of encouraging their activities as incidents of a general treatment. It will be noticed that little has been said in this chapter on the subject of Swedish exercises. This is not intended in any way to belittle their value. For a masseur to be thoroughly efficient they must be known and studied, and may replace those suggested or may supplement them. The ideal method of treatment is to instruct the patient in the appropriate exercises in the massage-room, and to allow him to perform them elsewhere, utilising the remainder of his time for massage, and for exercises of such a nature that he cannot perform them unless aided either by the masseur or by apparatus.

1 Oxford Medical Publications.

It will also be noticed that reference has always been made to the weight and pulley - never to the exerciser, lest we seem to allow the introduction of an elastic exerciser; which implement, while it may be good enough to serve as a "morning refresher," is useless for remedial work. The reason is simple. The resistance is least when power is at its greatest, and increases almost in proportion as the power of the muscle (from the posture of the limb) decreases.

The use of the terms "weight and pulley" apparatus, "ladder," "roller and rotator," etc., may sound rather formidable. A little ingenuity fortified by some kitchen weights, a pulley, one or at most two hooks, a chair, a stool, an iron bedstead, and a door-handle - the injured hand turns one handle while the sound hand resists or assists the turning of its fellow on the opposite side - will suffice for nearly every need. The addition of a broom-handle and an iron poker to the armamentarium is always useful.