J I ^ X^XA rial P?J elf. TESTING THE EFFECTS 21 August Hoffmann was quite right in the assertion which he made at the Congress fur innern Medizin in 1902, that acute dilatation is the most dangerous affection of the muscle of the heart. In this instance it is what may be called deceptive dilatation of the heart, and is produced by the heart working in an excited manner and giving off longer acoustic waves. In any case, this deceptive dilatation that is to say, the sudden appearance of a divergence between the optical (ortho- diagram) and the acoustic (percussion) outlines is a warning that we must be cautious in prescribing work. Their coinci- dence again is indicated by simultaneous improvement of the pulse and blood-pressure. We may be sure that in the majority of cases the heart which shows this very irritable type of action (v. Criegern) will also show marked modifi- cations in the blood-pressure of the character of (9) (strain according to Moritz). As it returns to normal, the acoustic outline also returns to that of the orthodiagram. We find this phenomenon very frequently in neurasthenics suffering from heart affection. A suitable course of gymnastics, especially in conjunction with a course of baths, causes it to disappear. In these cases, when the action of the heart is turbulent, the more the acoustic outline approaches the optical, so much the better will be the condition of the blood-pressure and of the pulse, and so much the more will the patient be sensible of the improvement which has taken place in the state of his health. But, on the other hand, by more minute observation we may be able, after severe gymnastic exercises, when the state of the blood-pressure and of the pulse is not favourable, to ascertain from radiographs that the heart is smaller than formerly. In that case we may have to do with overloading of the greater circulation. Here an examination of the blood-pressure will assist us in testing whether the de- crease of the heart's shadow is to be regarded as favourable or not. The result obtained usually corresponds to varia- 22 GYMNASTICS FOR HEART AFFECTIONS tions (3) and (5), and in the most unfavourable cases to variation (7). This unfavourable reduction of the silhouette of the heart, which, according to Kraus, is due to imperfect filling of its cavities, is not a satisfactory sign. It arises through func- tional weakness of the heart which is not strong enough to carry on properly the flow of blood in the greater circulation. Equally unfavourable is enlargement of the heart, which, especially when the walls of the right ventricle are weak, is produced by its strength not being sufficient to carry on effectively the lesser circulation through the lungs. We also find in the bad results shown by the blood-pressure (falling below and remaining under the normal) confirmatory evidence of an unfavourable nature. In these cases baths (especially alternating current baths), in conjunction with carefully conducted gymnastics, act very beneficially much better and more energetically than CO., baths. In cases where we have only to deal with irritable action, the strong stimulus of the alternating current increases the irritable condition. Oxygen baths and weak CO., baths should, on account of their soothing effect, be given in such cases. It must not be forgotten, also, that hydrotherapy acts often in a marvellous manner in consequence of the stimulating effects of temperature. The object of employing these various means of relief is to overcome the resistance of the muscular coats of the vessels. Graupner has, as far back as 1896, rightly laid stress on this being the principal effect of the Nauheim baths. Absolute increase of the work of the heart, such as can be obtained by the action of digitalis (and as we can also get by means of suitable gymnastics), cannot be obtained by baths. CHAPTER V Testing- the Influence of Gymnastics by Sommer's Analysis of Movements Observations on Respiration. T^ESIDES the means of investigating and controlling -D the influence of gymnastics just discussed, we have been trying another method, which is very sensitive in show- ing the slightest sign of fatigue. It is still very new, and requires to be tested much more extensively. But from the experience we have had of it we consider it very useful, and should not like now to do without it. It consists in testing fatigue by means of Sommer's Analysis of the ex- pression of motion. 1 Every trembling movement of the extremity is divisible into three phases : a movement from before backwards and vice versa, a movement to the side, and a movement from below upwards and vice versa. By means of an ingenious apparatus Sommer has succeeded in splitting up and register- ing graphically any trembling movements which may occur unconsciously and uninfluenced by the will of the person under observation, into the three above-mentioned com- ponent parts. If when a person comfortably seated holds out his leg in an extended position there be no trembling movement present, three straight lines will be registered on a revolving cylinder covered with blackened paper (Figs. F and H) ; but if there be any trembling motion, the upper line will show the trembling motion from below upwards, and from above downwards, the middle line will show the side movements, and the lowest line those from before backwards 1 Psychopathologische Untersuchungsmethoden v. A. Robert Sommers, Prof. Dr. Med. u Phil., Urban und Schwarzenberg. 23 24 GYMNASTICS FOR HEART AFFECTIONS and the reverse. In Figs. F and H are shown tracings of a leg held perfectly still, and in Fig. I a violent tremor is depicted. In our experiments we always used the leg, and tested the same limb always before and after exercise in the following manner. The patient having seated himself comfortably on a chair was told to extend his leg, which was supported while round the ankle was being placed a manchette connected by means of a rod to the writing works of the instrument in such a way that the slightest movement of the leg was directly transmitted to it, and the jerks corresponding to the three phases registered. After the manchette was fixed, the patient was told to hold out his leg unsupported and keep it quietly but not too rigidly extended, and to shut his eyes. The cylinder was then made to rotate, and on the smoked paper round it were recorded three more or less regular lines showing the absence of tremor or its presence in a stronger or feebler degree in the limb. From the four tracings figured it will be seen that there is no difference between Fig. F, taken before, and Fig. G, taken after resisted gymnas- tics ; whereas there is a marked difference between Figs. H and I, also taken before and after resisted gymnastics. The latter figure shows the tracings of great fatigue. 1 The theory of this control is based on the fact that the person whose muscle is tired is not able to hold his leg out straight with the same ease as when his muscles are not fatigued. He must exert himself when he is tired to do the same thing that he could do, when fresh, without fatigue or strain. The strain of the muscular system that is to say, the energetic contractions of the quadriceps is indicated by more or less strongly marked tremulous move- ments. It is an excellent illustration of Moritz's "will- strain and fatigue" shown unconsciously by a tired patient. 1 Fig. I was taken intentionally when the limb was very tremulous for tin- urpose of demonstrating the tremors clearly. SlAieflORMALSCHUUi, , CKttt. TESTING THE INFLUENCE 27 In this control the nature of the variations in the three com- ponent curves informs us whether or not too much has been done by the patient. The results given by the pulse and blood-pressure may be confirmed or differentiated by this method. Thus, if after gymnastics the result of an examina- tion of the blood-pressure is unsatisfactory while that of the analysis of the expression of motion is good, we may be sure that the blood-pressure and the pulse will soon change for the better. At the Congress fiir innern Medizin, 1907, F. Klemperer laid stress on the fact that he has found all the curves, i.e., Graupner's Pathognostic blood-pressure curves, in healthy persons as well as in invalids. We can also confirm the statement that blood-pressure curves, apparently morbid, are frequently obtained from healthy persons. But stress must be laid again on the fact that one method of investigation only is not sufficient for all requirements. If by different methods of research (as, for example, those already men- tioned) we find pathological conditions or deviations from the normal present in each instance, then we are fully justified in speaking of them as morbid conditions, as we have then a criterion to go by. It is only by taking into account the several results derived from different researches by different methods that we can obtain sufficient information. Thus by auscultation of the heart we can discover with certainty valvular defects. But it is from the blood-pressure, the pulse, the orthodiagram, functional examination (for example, by Rumpf's method), examination of the liver, urine, lungs, etc., that we discover whether or not the valvu- lar deficiency is compensated or the heart is easily fatigued. A markedly different finding after a single research by one method of investigation should not induce us to form a premature judgment of the case, but should incite us to try all the other methods, so as to guard ourselves as far as possible against the danger of being deceived. The most 28 GYMNASTICS FOR HEART AFFECTIONS painstaking observation is especially necessary in the medical control of gymnastics. It is in this way only that the patient can obtain what he expects of us, and we ourselves will find satisfaction in our work. In conclusion, we have still to mention one very impor- tant kind of research, which is also one of the earliest. It is observation of the Respiration. After the exercises it should show no unfavourable symptoms as regard either frequency or depth. An old practitioner used to make his heart-affected patients go up a short flight of stairs, first slowly and then quickly, to test the action of their hearts. Then from the condition of the pulse and the respiration after each test he used to draw his conclusions, which always stood him in good stead. In this way he obtained the com- bined results of two methods of investigation, even though they were only of the simplest and readiest kind. CHAPTER VI The Different Ways in which Gymnastics may be Used Their Object IN plates 1-42 are shown photographic reproductions of those exercises, which in the opinion of the authors are best suited for the gymnastic treatment of heart affec- tions. The exercises may be practised either as 4< passive" or as "active" gymnastics. At the outset it should be stated that exercises i to 8, which should be done while the patient is lying in a recumbent position, may also be used as resistance gymnastics by instructing the patient to perform the movements against resistance offered by the person who is superintending the gymnastics. As during the early stages of convalescence passive gymnastics are in the first instance principally wanted and have to be under- taken in the lying position, we have preferred to illustrate them being done in that position and in the passive form. When the patient has so far improved that he can practise the gymnastics sitting or standing, passive gymnastics are only suitable for the first few sets of exercises at most. In passive gymnastics the patient, having assumed the proper position for the exercise, relaxes his muscles entirely as in sleep; the superintendent then proceeds to perform the different exercises upon him while he does not exert his muscles in any way. Thus, for example, the superintendent (designated H throughout the series of exercises) raises the patient's leg, rotates his trunk, etc., while the patient himself (designated G in the exercises) does absolutely nothing. He simply allows his arms, legs, and trunk to be moved without his putting forth any nerve energy into 3' 32 GYMNASTICS FOR HEART AFFECTIONS his muscles ; in short, he is entirely passive as regards the gymnastics. As the cure progresses the patient proceeds to active gymnastics with resistance ; that is, he performs the different exercises himself by innervation of his muscles ; he bends his forearm, for example, instead of having it bent for him, while the superintendent resists his action gently at first but with increasing force. We can readily appreciate how exceedingly varied the graduations may be made in these gymnastics beginning with the smallest possible exertion, such, for example, as is entailed in simply raising and lowering the fully relaxed arm of a person resting quietly in a horizontal position, up to the strong resistance which can be offered when the exercise is performed by the patient. The exercises require more effort on the part of the patient when done without the assistance of the super- intendent, and also the more slowly they are executed. The patient is directed to bend the arm slowly and to straighten it again, to raise the leg slowly and then to lower it, to rotate the trunk slowly, etc. When practised in this way without assistance the exercises should be per- formed by the patient without straining his muscles. They should also be done as slowly as possible and without strong will-power being brought to bear upon the muscles, so that muscular strain may be avoided as much as possible. Thus performed the gymnastics form an intermediate step between resistance gymnastics and actual self-resisted gymnastics, though in reality this is the lightest form of self-resisted gymnastics, since the patient must of necessity, in order to do the exercises as slowly as possible, permit a certain amount of self-resisting influence to come into action. These self-performed gymnastics without resistance when done slowly and without putting forth strained muscular action have an exceedingly soothing effect, especially in THE DIFFERENT WAYS 33 nervous patients (neurosis of the heart). We have often observed that the severer form of gymnastics without apparatus, in which there is strong innervation of the muscles and strained muscular action, are badly borne by neurasthenics, whereas this milder form never fails to produce its soothing action and to effect improvement and ultimate cure in these cases. The strain on the patient is still further increased when he is directed to apply to himself the resistance which had previously been offered by the superintendent. To do this the patient has to imagine that someone is impeding him in the performance of his gymnastic exercises. He has, for example, to imagine that when bending his arm some- one is resisting the movement by counter-pressure, and, with this thought fixed in his mind, to perform the gymnastic with an effort proportionate to the resistance which in his imagination is being offered. This highest step in our forms of gymnastics is termed self-resisted gymnastics (selbsthemmungs-gymnastik), as the patient himself supplies the resisting force in each gymnastic exercise. When practising this form of gymnastics, for which all the exercises of the series we have arranged and illustrated are suitable, the supervising control of the physician is especially necessary. Overstrain can very easily result from them unless each exercise is carefully graduated to the patient. One of our greatest authorities on gymnastics, Herz of Vienna, who has already been mentioned, has not inaptly employed this kind of gymnastics for testing the functional efficiency of the heart. Even a healthy person is easily tired if he attempts to do several self-resisted gymnastic exercises without previous practice. To deter- mine whether the patient is bringing into play sufficient counter-innervation while doing self-resisted gymnastics is not a difficult matter for the physician. It is more difficult 34 GYMNASTICS FOR HEART AFFECTIONS for him to determine whether the patient is not over-exerting himself by putting forth too much innervation. Neverthe- less he must estimate exactly the amount of effort the patient may be permitted to exert. To enable him to do this he must during the stages before self-resisted gym- nastics are begun namely, when passive and active re- sistance gymnastics are being practised form a clear idea in his mind of what his patient is able to do. He must now look out even more sharply than he did in the earlier stages for signs of approaching fatigue. For this purpose the use of Sommer's Method, previously described, has in our hands rendered us excellent service when training patients in this form of gymnastics. CHAPTER VII The Order in which the Gymnastics should be practised and their object Special exercises The Importance of Breathing properly during the exercises The Clothing during and after exercises Diet and Stimulants. WE have now to discuss generally the question of the order in which the exercises should follow one another. In the first instance simple passive gymnastics should be practised lying down, namely, the exercises i to 8 inclusive. When these exercises can be undergone without shosving any signs of fatigue, the patient can then proceed to passive exercises in the standing position, by adding to the exercises in the lying position some passive exercises standing. When sufficient progress has been made so that the patient is able to do all the exercises from i to 27 inclusive, one after the other, passively, without any signs of exhaustion, but of course with a short pause between each, active-resistance gymnastics may be begun in the lying position, in the first instance by introducing into the exer- cises formerly practised passively some slight resistance (as, for example, by offering slight resistance while the arm is bent by the patient in the lying position). Then gradually all passive movements are replaced by resistance exercises, till the patient can do these exercises one after the other without any exertion to speak of. Again, in the same way as we proceeded from purely passive gymnastics to resistance gymnastics, we pass on to self-resistance gymnastics. When we have reached the stage that the exercises can be done by the patient as self-resisted gymnastics without showing signs of fatigue, the patient may/be permitted to do the remainder of his gymnastic course without medical super- vision. But even then the patient should, especially at first, 35 36 GYMNASTICS FOR HEART AFFECTIONS consult his medical attendant at least once per week for pur- poses of control, so that the latter may satisfy himself that no overstrain has taken place in the interval. On an average at least half a minute will be required for each exercise, inclusive of pauses, and after each exercise a short rest should be taken. It must be remembered that these gymnastics are not for the purpose of amusement, nor is the object for which they are used to beat the record in acts of strength. Their sole object is to enable the organism to perform "certain work for a given purpose with the least possible excitement of the heart and vascular system." When we have reached the stage that a patient is able to perform the exercises of self-resistance gymnastics with the strongest counter-innervation without causing more than very slight excitement of the heart and vascular system, we may be sure that he will then be in a position to surmount the physical exertion of his daily life-x In the foregoing brief outline of our exercises we have always referred to those numbered i to 27 only. Figs. 41 and 42 show a gymnastic exercise with apparatus by which the patient can practise trunk-bending in the lying position. Raising the trunk from the horizontal to the vertical position is the most exhausting gymnastic exercise which we know, and to reduce the exertion it entails we designed the apparatus figured. By unfastening one or more of the spiral springs which, by their strong traction, assist the patient in raising himself, the exercise can be made more difficult. The object of this exercise is chiefly to strengthen the muscles of the abdomen. It is only intended for those patients who are able to do all the self-resistance exercises without much exertion. On patients whose digestion is out of order this exercise has a very salutary effect ; it is, how- ever, quite apart from our specific gymnastics. In heart affections we disapprove of every form of gymnastic exercise which favours the flow of a strong current of blood THE IMPORTANCE OF BREATHING 37 to the head, and lay it down as one of the first rules in gymnastics that the head should always be the highest point. We therefore disapprove of deep trunk-bending in the standing position, as in it the head is too deeply depressed and congestion is favoured. Exercise 28 takes the place of trunk-bending. In it the head always remains highest, as can be easily seen in Figs. 41 and 42. Finally, another exercise which we have not figured, as it is so generally known, is knee-bending. This exercise also we can only recommend for those who have gone through self- resistance gymnastics with success ; for other patients it is too exhausting. It has a special value, however, as in it we possess an excellent means of testing functional efficiency. A patient who, before beginning gymnastics, shows signs of fatigue after bending the knee once or twice may at the conclusion of a gymnastic cure easily bend it a dozen times without our being able objectively to detect any tiring effect from the exercise. Breathing plays an exceedingly important part in gym- nastics. The lightest form of passive gymnastics forebodes only too frequently a strain on heart patients. Every muscle when working requires oxygen, and a supply of this gas must be provided for in the most rational way during gymnastics. This can be best effected by introducing breathing pauses during the gymnastics, and by letting the patient take deep respirations (abdominal breathing) as often as possible, not only during the course of an exercise, but also between each exercise. On the other hand, we must also take care not to make him take deep breaths while he is in positions which are unsuitable for abdominal breathing. Thus it would be wrong to let a patient stop to take a deep breath during gymnastic 27, Fig. 40. It is especially de- sirable that at the conclusion of the gymnastics task the patient should take twenty to thirty deep respirations while lying down resting. ;,8 GYMNASTICS FOR HEART AFFECTIONS The clothing worn while the gymnastics are being practised should be as light as possible, the patient should at least take off his coat and collar. The ideal condition under which all these exercises should be taken is in as large and airy a room as possible. During a gymnastic cure this is not always possible, but when the patient has finished his cure under his physician and is to continue the exercises independently at home, this condition should be impressed upon him. Finally, it may be mentioned that after gym- nastic exercises a suitable cool rub down or a warm bath which is cooled down slowly is much to be recommended. For cooling down the baths Hofmann's cooling tubes are very useful, as they reduce the heat of the bath equally to the desired temperature either rapidly or slowly, whereas simply running cold water into a warm bath to cool it always does so unevenly. After gymnastics the patient should rest clothed as lightly as possible. If he has perspired during the gymnastics he should change his underclothing when finished, and should not mind the trouble this entails ; for this purpose also he should always take with him fresh linen when he has to go to the physician for exercises, as it might be dangerous for a heart patient to go after his exercises into the cold air with damp underclothing, especially in winter. It naturally stands to reason that the best gymnastic as well as the most careful use of the best physical therapy will be useless if the invalid does not carry out definite dietetic measures. It may often be observed that even at large and famous health resorts the most promising cases become worse, because in the first place the patients are unreason- able in eating and drinking, and secondly, because in the hotels and pensions the care necessary in feeding invalids with heart affection is not taken. This is an old indictment which, curiously enough, no one will grapple with. It is not merely by the visit of the physician, by taking the baths DIET AND STIMULANTS 39 he prescribes and by practising gymnastic exercises under his eye, but also by following a definite mode of living with respect to eating and drinking that the cure will be success- fully effected. We are not fanatical supporters of abstinence theories, and have repeatedly learned from experience that a glass of good wine does not harm the patient but renews his vital energy. In spite of the risk of being thought behind the times, we nevertheless entirely agree with the old and distinguished authorities of the last century in this respect. We do not wish to say a single word in favour of indulgence in alcohol, but recommend moderation and lay stress on the fact that there are certainly many cases where use of alcohol must be entirely forbidden. It would be foolish to suddenly prescribe wine for a patient who for years past has not taken a drop of alcoholic liquor ; on the other hand, it appears to us to be very unnecessary, especially in the case of elderly gentlemen who have been accustomed to their glass of wine for years, to suddenly insist upon their becoming total abstainers. We have never seen any success from such a course, but we recollect well an elderly gentleman, who of his own free will promised to abstain from alcohol, and made so brilliant a gymnastic cure that he described himself and still does as a "record patient"; nevertheless, after six weeks of his cure; he confessed to us that he had drunk a glass of red wine every day at midday and half a litre of beer each evening, as he had been accustomed to do from his youth upwards. It did no harm to him then, nor does it do so now. Other exercises could have been added to the list described and figured, but those selected are, for the most part, recog- nised as being the best adapted for heart patients. The field of exercises should be better defined by the elimina- tions which have been made. In conclusion we must once more repeat the warnings : "The patient with heart disease must learn the gymnastics 40 GYMNASTICS FOR HEART AFFECTIONS from the physician. All movements and exercises in remedial gymnastics must be made slowly. All rapid movements (for instance, arm-circling) should always be avoided." DIRECTIONS FOR THE PERFORMANCE OF THE GYMNASTIC EXERCISES AND ILLUSTRATIONS. Explanation of the Text. G is used in the Direc- tions to designate the patient who is practising the Gymnastics. H denotes the person who super- intends the Exercises and aids in their performance. 44 45 No. 1. Figs. 1 and 2. G. lies comfortably on his back on a couch, with his limbs extended and his muscles fully relaxed. H. places himself at one side of the couch and takes hold of G.'s wrist with his hand corresponding to it, while he places his other hand on G.'s shoulder of the same side to fix it. H. now bends G.'s forearm slowly upwards and backwards on the upper arm. The extent to which the forearm should be bent is personal, and depends upon the amount of exertion G. may be permitted to have. That amount being reached, G. retains his arm for a few seconds in the flexed position and breathes deeply. H. then brings G.'s arm slowly back into its position of rest at starting. Exercise of the other arm then follows in the same manner. 4 6 47 No. 2. Fig. 3. G. lies comfortably on his back on a couch with his limbs extended and his muscles fully relaxed. H. places himself at one side of the couch near the foot, and taking G.'s hand nearest to him in his, moves slowly away from the couch and draws G.'s arm outwards from the body. The extent to which the arm should be moved is personal, and depends upon the amount of exertion G. may be permitted to have. That limit being reached, G.'s arm remains for a few seconds in the abducted position while he breathes deeply. H. then brings the arm slowly back to its original position. Exercise of the other arm then follows in the same manner. 49 No. 3. Fig. 4. G. lies comfortably on a couch with his limbs extended, his feet close together, and his muscles fully relaxed. H. places himself at the foot of the couch, and taking a light hold of the points of G.'s toes, rotates his feet slowly outwards. G.'s feet remain for a few seconds in the position shown in Fig. 4, and H. then presses them slowly together again. No. 4. Fig. 5. G. lies extended on a couch with his feet close together and his muscles fully relaxed. H. places himself at the foot of the couch, and taking hold of G.'s legs firmly above the ankles, raises the limbs slightly and draws them slowly apart. In this position (Fig. 5) they remain for a few seconds, during which G. breathes deeply. H. then brings the limbs slowly together again and finally lowers them on to the couch. 53 No. 5. Fig. 6. G. lies extended on a couch with his feet close together and his muscles fully relaxed. H. places himself on the right side and near the foot of the couch, and, taking hold of G. 's right foot by the heel with his right hand, slowly raises the leg and draws it outwards (i.e. abducts it), moving himself in the act a little away from the couch. The position being reached which is shown in Fig. 6, H. takes hold of the point of the toe with his left hand, and rotates it slightly outwards, then inwards, and finally back to the vertical position. A pause follows, during which G. takes a deep breath. After that H. brings the limb slowly back to its original position on the couch by reversing the previous movements. The other limb is then exercised, H. standing on the left side of the couch and taking hold of the ankle with his left hand and rotating the foot with his right hand. 54 57 No. 6. Figs. 7 and 8. G. lies extended on a couch with his feet together and his muscles fully relaxed. H. places himself at the right side of the couch, which he faces, opposite the patient's knees, and takes hold of the leg nearest to him just above the ankle with his right hand, while he places his other hand im- mediately above the knee-joint. H. then bends the limb slowly at the hip and knee joints by pushing the leg upwards till the thigh is at a right angle to the body and the leg and thigh form an acute angle with one another. In this position, shown in Fig. 7, the limb is allowed to remain for two or three seconds, during which G. takes a deep breath. After that H. raises the leg slowly, and, by simultaneously pressing gently with the hand on the knee, brings it into line with the thigh, as shown in Fig. 8 ; finally he lowers the extended limb into its original position. The left limb is then exercised in the same way. 59 No. 7. Fig. 9. G. lies extended on a couch with his feet together and his muscles fully relaxed. H. stands at his feet, which he takes hold of by the heels, and raises both limbs slowly, bend- ing them at the hip-joints while at the knees they are in an extended position, till they form an obtuse angle with the trunk, as is shown in Fig. 9. In this position they remain for a short time while G. takes a deep breath, which he should be able to do freely ; if any difficulty be experi- enced, the exercise is either unsuitable for him, or the limbs have been bent too much upward at the hip-joint. In the latter case the exercise may be repeated, but not on the same day ; and care should be taken that the limbs are not raised as high as on the previous occasion, so that the angle formed by them with the body is more obtuse. After G. has taken a deep breath, H. lowers the extended limbs to their original position. 6o 6i No. 8. Fig 10. G. lies on a couch with his feet together and his muscles fully relaxed. H. stands at his feet, and bending forward with outstretched hands, clasps G.'s hands, which the latter extends to him without moving from the horizontal position. H. now draws G. slowly towards him till G. is in a half- sitting attitude, and then, without any pause, lets him gradually sink backwards again into his original position of rest. 62 FIG. 1 1 No. 9. Fig. 11. G. stands with his feet together in the military position of attention, his arms hanging vertically from his shoulders. H. stands at his right side, and places his right hand on G.'s wrist and his left on G.'s shoulder. G. now bends his fore- arm upwards towards his shoulder without moving his upper arm, which remains firmly pressed against his body, the forearm only being moved in this exercise. H. resists the movement by counter-pressure downwards with his right hand, while with his left he prevents the shoulder being raised during the exercise. When the forearm has been flexed to the desired extent, G. forthwith brings it slowly back to the vertical position without making any pause between the movements. H. resists the return movement by counter-pressure, as shown in Fig. 11. Exercise of the left arm is then proceeded with in the same manner. FIG. 12 No. 10. Fig. 12. G. stands with his heels together in the military position of attention, and stretches one of his arms horizontally out- wards and forwards, the forearm being midway between pronation and supination. He now flexes the forearm, bringing the hand towards his face (Fig. 12). H. stands in front and to one side of him and resists the movement with his one hand, while the other is placed on G.'s shoulder so as to keep it fixed during the exercise. G. then, without making any pause, slowly brings his arm again into the extended position, while H. resists the movement. The other arm is then exercised in the same manner. 66 FIG. 13 68 FIG. 14 No. 11. Figs. 13 and 14. G. stands with heels together in the military position of attention. He extends his arms forwards (Fig. 13). FL takes hold of them from below. G. now moves them outwards (Fig. 14), whilst H. resists the movement by exerting counter-pressure. In doing so H. must advance towards G. by short steps. The extent to which G. may expand his arms is personal, and depends upon the amount of exertion which it is desirable for him to have. That being reached, G. takes a few deep breaths. H. then taking hold of G.'s extended arms above the wrists from their inner (or front) surfaces offers resistance, while G. brings them back to the position at starting. During the return move- ment H. must take a few steps backwards. FIG. 16 73 No. 12. Figs. 15 and 16. G. stands with his heels together in the military position of attention. He stretches out his arms in front of him, Fig. 15. H. takes a light hold of his wrists. G. then raises his extended arms, Fig. 16, to which H. offers resistance by light pressure downwards. While resisting the movement H. must advance a few steps towards G. The height to which G. may raise his arms is personal, and depends upon the amount of exertion which it is desirable for him to have. That being reached, G., without any pause and without breathing deeply, brings his arms back slowly to the position they were in at starting, whilst H. resists the movement by counter-pressure upwards, Fig. 16. In doing this H. must take a few steps backwards. 74 FIG. 17 S1AJBSORMALSCHOOL , OKI;. 77 No. 13. Figs. 17 and 18. G. stands in the military position of attention. H. places himself in front of him and takes hold of both his arms above the wrists as they hang by his sides, Fig. 17. G. now moves his arms outwards and upwards, while H. resists the action by counter-pressure downwards. The extent to which G. should raise his arms is personal, and depends upon the amount of exertion which it is advisable for him to have. When that has been reached, H. takes hold of G.'s arms in the manner shown in Fig. 18, and by counter-pressure upwards resists his action in bringing them back to the position at starting. This exercise is per- formed without any breathing pause between the upward and downward movements. 78 FIG. if) 79 No. 14. Fig. 19. G. stands firmly in front of H. and moves his arms back- wards from the vertical position. H. resists the movement by counter-pressure from behind forwards, as is shown in the illustration. The extent to which G. should move his arms backwards is personal, and depends on the amount of exer- tion which it is advisable for him to have. That being reached, G. , without making any pause, brings his arms back to the position at starting, while H. resists the move- ment by pulling them backwards. So Si No. 15. Fig. 20. G. stands with one foot in advance of the other and bends both arms at the elbow till they rest against his chest. H. places himself in front of him and takes hold of both his wrists. G. then slowly thrusts his arms forwards as if he would bring his hands towards H.'s breast. H. resists the movement by counter-pressure, as seen in Fig. 20. During the return movement to the position at starting H. offers resistance by counter-traction. Xo breathing pause takes place during this exercise. 82 FIG. 21 8 4 FIG. 22 No. 16. Figs. 21 and 22. G. stands with his feet somewhat apart and his arms extended from his sides, in the position shown in Fig. 21, the upper arms horizontal and the forearms bent at right angles to them and elevated to the vertical, the flexor surfaces directed forwards. Retaining his arms flexed at right angles, he moves his forearms forwards and down- wajds by rotating the humerus at the shoulder-joint. H. stands in front of G., and taking hold of the arms near the wrists resists the movement. G. then, without pausing, pro- ceeds to raise his forearms again to the vertical position, while H. resists the action (Fig. 22). The arms may be exercised separately instead of simul- taneously. 86 FIG. 23 87 No. 17. Fig. 23. G. stands at attention and extends one arm horizontally outwards from his side, the hand being clenched. H. takes hold of G.'s clenched fist with both hands. G. rotates his arm from the shoulder-joint to the hand, first forwards and then backwards, while H. resists the movements by gentle counter-pressure, first in one direction and then in the other, as G. rotates his arm forwards and backwards. Exercise of the other arm follows after G. has had a breathing pause. [A considerable part of the movement in this exercise is pronation and supin'ation of the forearm.] 88 FIG. 24 Fir.. 2 No. 18. Figs. 24 and 25. G. seats himself comfortably on a chair with his legs bent at right angles to the thighs in the usual sitting position. H., standing on one side and bending forwards towards the legs, takes hold of the one nearest to him, placing one hand over the front of the ankle, the other hand across the front of the thigh (Fig. 24). G. straightens out his leg by raising it slowly from the vertical till it is in line with the thigh. H. resists the movement by pressing the ankle downwards. H. then moves the fingers of his hand behind the ankle (Fig. 25), and by pulling in an upward direction causes resistance, while G. bends his leg and brings it back into the position at starting. After a short breathing pause the other leg is exercised in the same manner. 94 FIG. 27 95 No. 19. Figs. 26 and 27. G. seats himself firmly on a chair with his legs close together. H. squats in front of him and lays his hands on the outside of each knee (Fig. 26). G., keeping his feet firmly against one another, draws his knees apart, which H. resists by counter-pressure. The extent to which G. should separate his knees is personal, and depends upon the amount of exertion it is desirable for him to have. H. then places his hands on the inner sides of G.'s outstretched knees (Fig. 27) and offers resistance by pressing outwards in each direction, while G. brings his knees together again to their original position. During the exercise G. must breathe quietly. \o breathing pause is permitted between the out- ward and inward movements of the knees. 9 6 FIG. 28 97 No. 20. Fig. 28. G. stands erect with his feet together and rests both hands on the back of a chair placed in front of him to support him during the exercise. H. places himself behind G., and stooping down, links one hand round the leg to be exercised, just above the ankle ; the other hand he rests on the back of the thigh. G. slowly bends his leg at the knee, raising it backwards and upwards without moving his thigh from the vertical position, while H. resists the movement. The extent to which G. should flex his leg is personal, and depends on the amount of exertion it is desirable for him to have. G. then slowly straightens his leg and brings it back to the position at starting. H. resists the action by upward traction. Exercise of the other leg is then proceeded with in the same manner. [In doing this exercise there is often a tendency to move the thigh forwards. This can be readily prevented by H. placing his hand on the front of the thigh just above the knee instead of on the back of the thigh. To do this H. must place himself on the outside of the limb exercised.] 9 8 FIG. 29 1OO FlO. 30 101 No. 21. Figs. 29 and 30. G. stands erect with his feet together and rests both hands on the back of a chair placed in front of him to sup- port him during the exercise. H. stands behind him, and bending downwards in a stooping position, grasps the limb to be exercised just above the ankle with one hand held in the form of a fork ; the other hand he places above the buttock. Thereupon G., holding himself as erect as possible, moves the limb in the extended position backwards and upwards from the hip, while H. resists the movement (Fig. 29). The extent to which G. should move his limb back- wards is personal, and depends on the amount of exertion it is desirable for him to have. That limit being reached, H. now places his hand, bent in the form of a hook, round the front of the leg immediately above the ankle, his other hand remaining as before above the buttock (Fig. 30), and offers resistance by backward traction ; while G. brings back his still extended limb to the position it was in at starting. Exercise of the other limb is then carried out in the same manner. IO2 Fie.. 32 '05 No. 22. Figs. 31 and 32. G. stands erect with his feet together and places his left hand on the back of a chair by his side to support him when standing on his left leg during exercise of the right. H. places himself to the right and in front of G., and stooping down grasps G.'s right leg just above the front of the ankle with the right hand ; his left hand he places on the front of G.'s thigh. G. now raises his limb in the extended position forwards and upwards without moving his body from the erect position, while H. resists the movement by counter-pressure (Fig. 31). The extent to which G. should advance his limb is personal, and depends on the amount of exertion he may be permitted to have. That limit being reached, H. moves his hand round the back of the leg, as shown in Fig. 32. G. then brings his still extended limb slowly back to its position at starting. H. resists the return movement by traction forwards. After G. has taken a few deep breaths, and H. has reversed his own position and that of the chair (or G. has reversed his), exercise of the left limb is proceeded with in the same manner. io6 io8 FIG. 34 109 No. 23. Figs. 33 and 34. G. stands erect with his feet together and places his left hand on the back of a chair placed by his side to support him so that he may be able to stand firmly on one leg while the other is being exercised. H., standing on G.'s right side and bend- ing down, takes hold of his right leg just above the ankle with the right hand, his left being placed on the outside of G.'s hip. G. now abducts his extended limb, raising it slowly outwards and upwards, while H. resists the movement by pressing it in the opposite direction (Fig. 33). The extent to which G. may abduct his limb is personal, and depends on the amount of exertion he is permitted to have. H. having moved his hand round to the inner side of the leg, G. begins the return movement of bringing the limb to the ground again, during which H. offers resistance to the downward progress of the limb by traction in the opposite direction. After exercise of the right limb a breathing pause follows, and then exercise of the left limb is carried out in the same manner. I IO 35 1 1 1 No. 24. Fig. 35. G. stands with his feet together in the military position of attention. H. places himself in front of G. and grasps him by both shoulders (Fig. 35). G. twists the upper part of his body slowly round, first to the right and then to the left, without altering the position his legs were in at starting. H. resists the movement by alternate counter-pressure, first on the right and then on the left shoulder. The extent to which G. should rotate his body to the right or to the left is personal, and depends on the amount of exertion which it is desirable for him to have. During this exercise there is no breathing pause between the movements. I 12 I I No. 25. Fig. 36. G. stands erect with his feet together in the military posi- tion of attention. H. stands behind him and places his right hand on G.'s right shoulder, his left being placed on G.'s left hip. G. bends the upper part of his body to the left, as seen in Fig. 36, keeping the lower part of his body as straight as possible. Meanwhile H. resists the movement by pressing the shoulder downwards. The distance G. should bend to the side is personal, and depends upon the amount of exertion it is desirable for him to have. That being reached, G., without any pause, returns to the erect posture, while H. resists the movement by pressure with his left hand against G.'s hip. Bending to the right is then practised in exactly the same manner, the position of H.'s hands being reversed for it. [Resistance in this exercise is, in the opinion of the Trans- lator, best offered by H. placing his left hand on the external surface of G.'s left upper arm near the shoulder, i.e. upon the deltoid muscle of the side to which G. is going to bend, the other hand resting on G.'s opposite hip. As G. bends to the left (Fig. 36), H. resists the movement by pressing the left shoulder in the opposite direction with his left hand, while his right, pressing on G.'s right hip, assists in keeping the lower part of his body erect. For the return movement, which is made without any pause, H. reverses the position of his hands quickly, and resists the movement with both hands, but chiefly with the right. His hands are now in position to resist the movement of bending to the right, which is proceeded with after a short pause, and when the exercise is completed his hands are in the same position as they were at starting.] FIG 37 n6 Fio. 38 No. 26. Figs. 37 and 38. G. stands with his feet together in the military position of attention. H. stands close by him and lays one hand on the middle of his chest (Fig. 37) ; the other hand rests on his back, between his shoulder-blades (Fig. 38). G. then bends his head and chest forwards. H. offers no resistance, but only prevents any actual forward movement taking place from the hips. The extent to which G. should bend his head and chest is personal, and depends upon the amount of exertion which it is desirable he should have. That being reached, he returns slowly and without any pause between the movements to his original position at starting. n8 12O FIG. 40 121 No. 27. Figs. 39 and 40. G. stands erect, but holds himself as laxly as possible. H. places himself opposite G.'s right side and places his right hand on the pit of G.'s stomach (epigastrium), Fig. 39 ; his other hand is placed on G.'s back, between the shoulder- blades, Fig. 40. G. then bends the upper part of his body backwards. To this H. offers no resistance whatever, but only steadies the patient and prevents the bending back- wards being carried so far as to cause straining. The extent to which G. may bend backwards is personal, and depends on the amount of exertion he may be permitted to have. That being reached, G., without any pause and without any resistance whatsoever on the part of H., returns slowly to the erect position. 122 124 No. 28. Figs. 41 and 42. G. lies comfortably on a couch and pushes his feet through a leather stirrup attached to a footboard in the manner shown in Fig. 41. The footboard is thus held firmly in its position. G. takes hold of the cross-bar of the apparatus with both hands and pulls it till the springs are tightly stretched. Then by a series of forward and backward movements of his body, during which the springs are alternately relaxed and tightened, he brings himself into a sitting position. During the process of raising himself he must keep his lower limbs fully extended, and must not bend his knees even to the smallest extent. When in the sitting position he takes a few deep breaths. After that he permits his body to fall back gently to the recumbent position by dint of stretching the springs and pressure of his extended limbs against the foot- board (see Fig. 42). Again there is a breathing pause. This exercise is not included amongst the general gym- nastic exercises, but should be practised as a special one. It is particularly suitable for patients suffering from con- stipation and flatulency. INDEX Abduction of Lower Limbs, 50, 51 Abduction and Rotation of Lower Limbs, 52, 53 Action of Drug's, 6, 7 Action of Physical Methods, 6, 7 Active Gymnastics, 32 Acute Dilatation of Heart, 21 Alcohol in Heart Affections, 39 Alternating' Current Baths, 22 Apoplexy, Use of Baths and Exercises in, 5 Arm Abduction, 46, 47 Arterio-Sclerosis and Physical Treat- ment, 5 Auscultation of Heart, 20 Backward Stretching of Arms, 78, 79 Blood-Pressure, Directions for deter- mining', 18 Bradycardia, 14 Breathing' during Gymnastics, 37 Carbonic Acid Baths, ix Care required in prescribing Physical Treatment, 9 Clothing during Gymnastics, 38 Cooling Tubes for Baths, 38 Danger of Physical Methods used by Unqualified Persons, x Deceptive Dilatation of Heart, 21 Diet during Gymnastic Course, 38 Difficulties in Sending Patients to Bad-Nauheim, viii Directions for Gymnastic Exercises, 4i Directions for taking Blood-Pressure, 18 Doing too much, i Drugs versus Physical Methods of Treatment, 6 Effects of Gymnastics on Blood-Pres- sure, 18, 19 Effects of Gymnastics on Irregular Pulse, 14, 17 Errors in Performance of Gymnas- tics, x Extenso-flexion of Forearm, 64, 65 Extension of the Leg, 88-91 External and Upward Stretching of Arms, 74-7 Flexion of Forearm, 62, 63 Flexion of Leg and Thigh, 54-7 Forearm Bending, 42-5 Forward Thrusting of Forearms, 80, 8 1 Forward and Upward Stretching of Arms, 70-3 Graupner, 22, 27 Gymnastics in After Treatment of Heart Weakness, 6 Herz, 2, 33 Horizontal Extension of Arms, 66-9 Importance of Physical Methods, vii Instructions of Physician must be closely followed, 3 Irregular Pulse, 14 Klemperer, 27 Knee Abduction and Adduction, 92-5 Kraus, 22 Leg Flexion, 96, 97 Leg-Raising Sideways (Abduction), 106-9 Lightening the Work of the Heart, 7 Medical Supervision, viii, 9, 33 Moritz's Symptom of Strain and Exhaustion, 20, 21, 24 Muller Exercises, i 128 INDEX Object of Gymnastics, 36 Observations on the Pulse, 10 Observing Effects of Gymnastics, 10 Oertel Terrain Cure, 2 Order of Gymnastic Course, 35 Oxygen Baths, 22 Passive Gymnastics, 31 Pathognostic Blood-Pressure Curves, -27 Percussion of Heart, 20 Phases of Movement, 23 Physical Methods most useful in Early Stages, 4 Physical Methods must be supervised by Physician, viii, 9 Principal Systems of Gymnastics, i Raising Lower Limbs, 58, 59 Reduction of Obesity, 8 Reduction of Pulse Frequency by Gymnastics, 14 Reduction of Silhouette of Heart, 22 Remedial Gymnastics suitable for some cases only, i Researches on Blood- Pressure, 18 Resistance Gymnastics, 32 Respiration, Observations on, 28 Rest required with Physical Methods, 7 Riva-Rocci's Method of determining Blood- Pressure, 18 Rotation of Extended Arm, 86, 87 Rotation of Feet, 48, 49 Rotation of Upper Arm, 82-5 Rumpf s Method, 27 Self-performed Gymnastics, 32 Self-resisted Gymnastics, 33 Scepticism regarding Physical Me- thods, viii Schott, August, viii, xi Selection of Cases for Physical Treat- ment, 4 Selection of most suitable system of Remedial Gymnastics, 3 Sommer's Analysis of Motion, 23, 34 Swedish Remedial Gymnastics, 2 Systems of Gymnastics for Heart Affections, i Thigh Extension, 102-5 Thigh Flexion, 98-101 Time required for Exercises, 36 Translator's Preface and Introduc- tion, vii Trunk Bending, 36 - backwards, 118-21 forwards, 114-17 sideways, 112, 113 twisting, 108, 11 1 raising, 60, 61, 122-5 Unsuitable cases for Physical Me- thods, 4 Various Conditions of Blood-Pressure after Gymnastics, 18 X-rays Examination of Heart, 20 Zander System of Gymnastics, 3 WILLIAM BKKNDON AND SON, LTD. PRINTERS, PLVMOUTH UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. Form L9-10w-6,'52(A1855)444 721 H67E Hofmann ' Remedial gymnast 1' for heart affections *RM 721 H6?E I I'll in ri ii A 001410723