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 HEART AFFECTIONS 
 
 USED AT BAD-NAUHEIM 
 
 BEING A TRANSLATION OF 
 
 "DIE GYMNASTIK DER HERZLEIDENDEN" 
 VON 
 
 DR. MED. JULIUS ^HOFMANN UND 
 DR. MED. LUDWIG POHLMAN 
 
 BERLIN UND BAD-NAUHEIM 
 
 By JOHN GEORGE GARSON, M.D. EDIN., &c. 
 
 PHYSICIAN TO THE SANATORIA ANO RA U-N AUHCIM, EVERSLEY, HANTS 
 
 FIFTY-ONE FULL-PAGE ILLUSTRATIONS AND DIAGRAMS 
 
 PAUL B. HOEBER 
 
 69 EAST 59 STREET 
 
 NEW YORK 
 
 191 1
 
 72] 
 
 TRANSLATOR'S PREFACE AND 
 INTRODUCTION 
 
 THE physical methods of treatment of affections of the heart 
 have made such marked advances in Germany during the 
 last twenty years that they can no longer be regarded as 
 the elaboration of a few enthusiasts. The relative rapidity 
 with which these methods have come to be recognised as 
 therapeutical measures of the first importance has no doubt 
 been greatly due to the existence there of natural thermal 
 springs, highly charged with carbonic acid gas and salines 
 specially suitable for bath purposes in cardiac affections. 
 The success which has attended the use of these waters as 
 baths in conjunction with certain remedial gymnastics, 
 selected on well-thought-out physiological grounds, has been 
 so great as to constitute a new chapter in the practice of 
 Medicine relative to the treatment of heart affections. The 
 greatest enthusiast of these methods would not pretend to 
 credit them with the powers of restoring to health and 
 strength persons whose hearts and blood vessels are hope- 
 lessly damaged and beyond repair. But fortunately these 
 are not the majority of the cases met with in practice. 
 Affections of the heart, as a rule, are attended with sufficient 
 discomfort to the patient to cause him at an early period to 
 seek medical advice while the affection is still amenable to 
 treatment, or at least while the condition of the patient can 
 be materially improved. As experience has been gained in 
 their use, the physical methods of treatment have been im- 
 proved and placed upon a firmer physiological basis ; their 
 capabilities also have been more exactly ascertained and 
 their limits of usefulness more accurately defined. In this 
 
 - 
 
 SOS flflCEUES,
 
 viii TRANSLATOR'S PREFACE 
 
 advancement of knowledge successive physicians at Bad- 
 Xauheim have played so important a part that the treatment 
 has become peculiarly associated with that health resort and 
 with the name of the late August Schott who did so much, 
 especially in early days, to evolve its principles and establish 
 its practice. 
 
 In England the adoption of these new methods has been 
 very slow. It is true that in most recent text-books dealing 
 with heart affections reference is made to the Nauheim 
 treatment, and the exercises elaborated by Schott are 
 frequently described. The latter are also taught to pupils 
 of massage. But notwithstanding the commendations of 
 several of our leading Physicians, both in their practice and 
 in their published works, it cannot be gainsaid that great 
 scepticism prevails in the medical profession of this country 
 as to the value of the methods, and comparatively few 
 practitioners of medicine are personally acquainted with 
 them. In Great Britain and Ireland we have no natural 
 springs highly charged with carbonic acid gas comparable 
 to those of Bad-Xauheim. To carry out the treatment, 
 therefore, as regards baths, artificial means of charging 
 the water with the salts and gas have to be resorted 
 to, or patients have to go to Bad-Nauheim to obtain 
 them. Although for several years past the number of 
 patients who have resorted thither has averaged about 
 one thousand annually, this is but a very fractional propor- 
 tion of the cases that would be benefited by the treatment. 
 Differences of language, habits, and customs, as well as 
 distance, must ever be formidable barriers in the way of 
 patients going to Bad-Nauheim for treatment. The attempts 
 which have been made to prepare the baths artificially at 
 home have for various reasons not been very successful, 
 although with proper apparatus for charging the water and 
 by the addition of chemicals in the proper proportion there 
 is absolutely nothing to prevent the treatment being carried
 
 TRANSLATOR'S PREFACE ix 
 
 out in its entirety with equal success in England as at Bad- 
 Nauheim, once the methods have been learned. It is being 
 done successfully all over Germany. The fact must also 
 be learned that properly charged carbonic acid baths cannot 
 be obtained by passing the gas through the water in the 
 bath, or by adding chemicals to generate the gas in the 
 water of the bath. To get the proper effects of carbonic 
 acid baths, it is essential that the water used for the bath be 
 charged with the gas under pressure, so that the latter takes 
 the place of the atmospheric air naturally held in the water. 
 The machinery required for this is expensive, and a pro- 
 perly equipped bath-house is necessary. Hospitals in this 
 country have not yet been provided with such appliances, 
 and, therefore, but few practitioners of medicine have had 
 an opportunity of seeing the physical methods carried out. 
 Yet those of us who have had the opportunity of studying 
 them thoroughly, know and realise the powerful effect for 
 good or evil they possess, accordingly as they are used 
 rightly or wrongly. The action on the heart of the 
 Nauheim baths and exercises is sometimes so powerful that 
 in some cases we may be able to obtain, by means of the 
 one or the other, in a few minutes, the effect we have been 
 trying in vain for weeks to bring about by means of drugs. 
 With remedies which may in some cases act so promptly 
 and potently, caution is very necessary even when the 
 physician is skilled in their use. And just as we do not 
 entrust potent drugs, such as hydrocyanic acid, digitalin, 
 strychnine, etc., to the hands of even trained nurses, except 
 under strict medical direction and supervision, so the 
 physician himself should always personally direct the 
 administration of these physical remedies when beginning 
 them on a patient, and carefully judge the effect they are 
 producing. After he is satisfied as to their action on the 
 patient, he may by degrees avail himself of the assistance 
 of a trained attendant, working under his supervision, in
 
 x TRANSLATOR'S PREFACE 
 
 carrying them out. The medical profession and the public 
 cannot be too strongly warned against the dangerous conse- 
 quences liable to occur from attempts being made to carry 
 out these physical methods of treatment in Nursing Homes 
 by persons who are not qualified medical practitioners, 
 whose only knowledge of them often is that they may have 
 learned the movements of the different exercises while 
 going through a course of instruction in massage, and who, 
 on the strength of this, advertise their Homes as places 
 where Nauheim treatment can be obtained. The qualified 
 medical practitioner will find that he has much to learn 
 regarding the administration of the remedial gymnastics 
 when he first begins their use. He should never begin by 
 practising them on a person whose heart is affected. At 
 first he is very prone to perform the movements too rapidly, 
 and to offer too much resistance when he attempts resisted 
 movements on the patient. It is only after considerable 
 practice that one comes to know instinctively the details, 
 and is able to observe from the appearance of the patient 
 whether or not too much is being done. Even when there 
 are no indications of strain it is not prudent to rely on visible 
 symptoms, and the means subsequently described in the 
 text should always be taken to test and control the effect of 
 the gymnastics on the patient. 
 
 This edition of Dr. Hofmann's work is presented in the 
 English language with the hope that it may be of assistance 
 to members of the medical profession who are desirous of 
 making themselves acquainted with that part of the Nauheim 
 methods of treatment of heart affections which can be 
 carried out in ordinary medical practice, and which, in suit- 
 able cases, gives excellent results, independently of the 
 Baths. When the latter are also available, under medical 
 supervision, the range of usefulness of the treatment is 
 vastly extended, and in many cases the combined treatment, 
 sometimes in conjunction with special massage, gives the
 
 TRANSLATOR'S PREFACE xi 
 
 best results. Before undertaking the task of translating 
 this work I had, by personal visits to Bad-Nauheim, oppor- 
 tunities of making myself thoroughly acquainted with the 
 various methods and appliances for treatment employed 
 there, and of discussing and testing the objects and 
 relative values of the several remedial gymnastics selected 
 for use by Dr. Hofmann in his splendidly appointed Sana- 
 torium. Although in the main these gymnastic exercises 
 are the same as the series propounded by the late August 
 Schott, several modifications and improvements have been 
 effected since his death in the mode of carrying them out, 
 new exercises have been added, and some of the original 
 ones have fallen into disuse. Subsequent experience in the 
 series recommended in this work has confirmed the favour- 
 able opinion I formed of them, and I have used them alone, 
 and, more recently, since 1 got the Nauheim Bath Institute 
 established at Eversley, in conjunction with the baths, with 
 much success. 
 
 In the translation of Dr. Hofmann's text I have adhered 
 as closely to the original as the idioms of the languages 
 would permit, but in the descriptions of the gymnastic 
 exercises I have taken greater latitude, and in some cases 
 have remodelled the directions entirely, when I have con- 
 sidered that by so doing these could be made clearer and 
 more simply expressed. In two instances I have given 
 alternative directions, which from practical experience I 
 
 have found desirable. 
 
 J. G. GARSON. 
 
 THE SANATORIA AND BAD-NAI HEIM. 
 
 EVERSLEY, HANTS, 
 
 October, 1909.
 
 AUTHOR'S PREFACE 
 
 IN the course of the development of modern therapy it has 
 been proved that, in the treatment of many diseases of the 
 heart and blood vessels, the same successful result is not 
 always obtained by the same means in different cases. In 
 pharmaceutical therapy this fact has long since been recog- 
 nised. It is therefore not to be wondered at that the same 
 thing should also hold good in physical therapy. Thus, 
 there are many persons suffering from heart affections with 
 whom carbonic acid baths, in any form, do not agree. 
 These patients, on the other hand, very often show an 
 excellent reaction to oxygen baths, or electrical manipula- 
 tions, especially to the alternating current baths. Splendid 
 results can also be obtained from certain gymnastic cures. 
 
 But in heart affections a therapy may be wrongly used. 
 "Overdoing," for example, is a veritable two-edged sword, 
 and just as a patient with heart affection can be benefited by 
 gymnastics properly used, so he can be made worse by 
 overdoing it or by a wrong use of exercises. 
 
 We have now collated the most essential exercises for a 
 gymnastic course without apparatus, so that our experience 
 may be at the disposal of Physicians and the public. The 
 book has been written from practice for practice. 
 
 DR. MED. JULIUS HOFMAXX.
 
 CONTENTS 
 
 PAGE 
 
 Translator's Preface and Introduction . ... vii 
 
 Author's Preface . . ... xiii 
 
 CHAP. I. Introduction The Chief Systems of Remedial 
 
 Gymnastics used in Heart Affections . . . i 
 
 CHAP. II. Indications for and against the Use of Remedial 
 
 Gymnastics and Baths in Heart Affections . 4 
 
 CHAP. III. Medical Supervision Necessary and Methods of 
 Controlling" the Effects of Gymnastics on the Patient 
 Observations on the Pulse . . 9 
 
 CHAP. IV. Testing the Effects of Gymnastics by Observa- 
 tions on Blood-pressure, Auscultation, Percussion, 
 Rontgen Rays . . . 18 
 
 CHAP. V. Testing the Influence of Gymnastics by Sommer's 
 
 Analysis of Movements Observations on the Respiration 23 
 
 CHAP. VI. The Different Ways in which Gymnastics may be 
 
 Used Their Object . . . . . 31 
 
 CHAP. 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 . . . . 35
 
 xvi CONTENTS 
 
 GYMNASTIC EXERCISES 
 A. PASSIVE, IN LYING POSITION 
 
 PAGE 
 
 1. Forearm-bending. . . 4 2 ~45 
 
 2. Arm abduction . . . 46-47 
 
 3. Rotation outwards of feet . ... 48 -49 
 
 4. Abduction of lower limbs . ... 5O-5 1 
 
 5. Abduction and rotation of lower limbs . . 52 53 
 
 6. Flexion of leg and thigh . . 54 57 
 
 7. Raising lower limbs . . . . 58 59 
 
 8. Trunk-raising from horizontal . . . 60 61 
 
 B. ACTIVE, IN STANDING OR SITTING POSITION 
 
 9. Flexion of forearm . . 62 63 
 
 10. Extenso-flexion of forearm . ... 64 -65 
 
 1 1 . Horizontal extension and spanning of arms . . 66 69 
 
 12. Forward and upward stretching of arms . . 70 73 
 
 13. External and upward stretching of arms . . 74 77 
 
 14. Backward stretching of arms . . . 78-79 
 
 15. Forward thrusting of forearms . . . 80 8 1 
 
 1 6. Rotation of upper arm with forearm bent . . 82-85 
 
 1 7. Rotation of extended arm . ... 86-87 
 
 18. Extension of leg . . ... 88-91 
 
 19. Knee abduction and adduction . . . 9 2 ~95 
 
 20. Leg flexion . . *. . . 96-97 
 
 21. Thigh flexion . . ... 98-101 
 
 22. Thigh extension . . ... 102-105 
 
 23. Leg-raising sideways (abduction) . . . 106 107 
 
 24. Trunk-twisting . . ... 108 in 
 
 25. Trunk-bending sideways . ... 112-113 
 
 26. ,, ,, forwards . ... 114 117 
 
 27. ,, ,, backwards . . . 118-121 
 
 28. Trunk-raising with apparatus . . . 122-123 
 
 Index i ?r
 
 REMEDIAL GYMNASTICS 
 FOR HEART AFFECTIONS 
 
 CHAPTER I 
 
 2. 2732. 
 
 Introduction The Chief Systems of Remedial Gymnastics used in 
 Heart Affections. 
 
 i( 
 
 T~) EMEDIAL gymnastics are, as a rule, suitable only in 
 AX. certain cases of heart affection, and the physician has 
 always to consider very carefully whether or not the patient 
 is able to endure the exertion they entail. Other patients, 
 again, are best suited by remedial gymnastics of a very 
 special kind. "Nee nemis" are the words of warning which 
 should ever be present in the mind of the physician when 
 prescribing gymnastic exercises. The reason for this is 
 that, while much good can be effected by the proper use of 
 them, they may cause just as much harm to the patient 
 when wrongly employed. As an illustration of this we need 
 only mention the injurious effects which have often resulted 
 from the M tiller exercises on previously healthy hearts. 
 
 Before proceeding to indicate which remedial gymnastics 
 are in our opinion the most suitable for heart affections we 
 must consider the following questions : 
 
 1. Which are usually considered the best remedial gym- 
 
 nastics for heart affections? 
 
 2. Are several systems equally good ? If so, which is the 
 
 least expensive and generally the most practicable 
 for the patient to carry out wherever he may be ? 
 
 3. In what affections of the heart should treatment by 
 
 remedial gymnastics, as a rule, be avoided, and 
 which exercises should, in certain cases, in the 
 interests of the patient, be omitted? 
 
 The answer to the first question is that there are three 
 systems of remedial gymnastics which specially claim our
 
 2 GYMNASTICS FOR HEART AFFECTIONS 
 
 attention, namely, that of the distinguished Austrian Herz, 
 the Swedish remedial gymnastics, and that, also of Swedish 
 origin, elaborated more especially by the late August Schott. 
 A fourth method, the Oertel Terrain cure, must be 
 mentioned, though it is not on a par with any of the other 
 three systems just named. The absence of supervision 
 during exercise, not being able to take rest immediately on 
 the appearance of fatigue, and the long interval, at least 
 twenty-four hours, which has to elapse before the exercise 
 can be repeated, make the Terrain cure generally impractic- 
 able. Again, for a Terrain cure, the invalid has to walk 
 a certain distance along a road, and then back to the 
 place from which he started. Should, for example, a 
 walk of one hour have been prescribed for the Terrain 
 cure, and the patient have reached the furthest point to 
 which he has to go, situated at a distance of half an hour 
 from his home, it is a very unpleasant experience for him 
 if he then finds himself suddenly overtaken by fatigue. 
 He has still half an hour to walk before he can get home, 
 and, by that time, may be in a very exhausted condi- 
 tion. In a remote sanatorium at which the author was 
 formerly an assistant he has several times seen this actually 
 occur, when, in consequence of the condition of the patient 
 appearing to be better than it really was, too long a walk 
 had been prescribed, or, as more frequently happened, when 
 patients of their own accord took longer walks than they 
 should have done. He has repeatedly seen patients who 
 were undergoing a Terrain cure brought home on a hay 
 wagon in an extremely exhausted condition. That in itself 
 would not have been so serious did not the overstrain always 
 delay the success of the cure. The Terrain cure can only be 
 taken in safety in grounds surrounding a residence on roads 
 specially constructed for the purpose, and arranged so that 
 the walk can be stopped at any time and rest taken forthwith 
 on the appearance of fatigue.
 
 INTRODUCTION 3 
 
 We need therefore only consider the three systems 
 previously mentioned, and of these the last-named is, with 
 certain modifications and some omissions, in our opinion, 
 the most serviceable. In making this selection we are far 
 from depreciating in any way the value of the Herz and 
 Zander systems of remedial gymnastics, but the system 
 which we more particularly favour requires no apparatus, 
 and, if the patient wants assistance, it can be rendered to him 
 by a member of his family, a servant, or a friend. For the 
 other two systems very costly apparatus is in part necessary. 
 In a sanatorium all the three systems are equally valuable, 
 but for home use that to which we have given the preference, 
 because of its requiring no apparatus, being equally good, 
 simple, and the cheapest, is, in our opinion, most to be 
 recommended. 
 
 If a patient is physically fit to undergo gymnastic 
 treatment, he should in his own interest place himself for 
 some time under the care of a physician, or in a well- 
 conducted medical institute, to learn how he should do the 
 gymnastics and which exercises are most suitable for him. 
 He should explicitly follow the instructions of the physician 
 under whose supervision he is, and learn by heart the direc- 
 tions given him. "Do such and such an exercise in this 
 way and for so long." "In this exercise take a deep breath 
 at this point," etc. During the first few weeks the effect of 
 each gymnastic exercise should, if possible, be controlled by 
 the physician, so that he may add further exercises, or stop 
 such as are not suitable for the patient. Should at any time 
 the patient find that an exercise causes him any abnormal 
 sensation, he should not console himself with the idea, "Oh, 
 it will soon pass off," but should at once discontinue the 
 exercise and consult his physician. This is especially neces- 
 sary at the beginning or if the patient is not under the 
 immediate supervision of the physician.
 
 CHAPTER II 
 
 Indications for and against the use of Remedial Gymnastics 
 and Baths in Heart Affections. 
 
 WE have now to consider the fundamental principles in- 
 volved in the answer to the question, Who should 
 avoid gymnastics and who should use them? This question 
 has been answered by Romberg, 1 of Tubingen, in a short 
 and concise paper in the following manner : 
 
 "Turning now to the indications and centra-indications, 
 it follows from what has just been said that both methods of 
 strengthening the heart [baths and gymnastics] are only 
 suitable in the initial stage of the disease. It is only then 
 that the heart possesses a certain definite store of reserve 
 strength with the help of which it will be able to respond to 
 increased demands cautiously made upon it. If the stage 
 of severe disturbance of the circulation has already begun, 
 if the heart is already during rest no longer in a position 
 to maintain an approximately normal circulation, if there be 
 continuous and severe dyspnoea during rest, if persistent 
 oedema and effusion into the body cavities be present, then 
 baths and gymnastics are no longer suitable for the patient. 
 After the heart has materially improved they may perhaps 
 be considered desirable. Equally unsuitable are patients 
 suffering from pronounced angina pectoris and attacks of 
 cardiac asthma, as experience shows that dangerous attacks 
 may be brought on by any increased demand on the heart. 
 Similarly unsuitable also are cases in which fresh dis- 
 turbances have occurred after manifest over-exertion or after 
 an infectious disease. These are benefited only in their later 
 stages by the treatment. 
 
 1 " Uber die physikalischc und di;ltetische Behandlung der Herzkrankheit," 
 Prof, von Romberjc, Tubingen. Medizinisches Korrespondensblatt dcs tvilrt- 
 ttmbergischen iirztliclicn Laiidesverht, Hd. 77, \r. 26, vorn 29 Juni 1907.
 
 INDICATIONS FOR AND AGAINST 5 
 
 "Great attention should be given to the condition of the 
 vascular system. When considerable arterio-sclerosis is 
 present and the blood-vessels are consequently more or less 
 incapable of adapting themselves to the changing demands 
 upon them, we must remember that the blood requirements 
 of the body have to be regulated by the heart much more 
 than under normal conditions. In arterio-sclerosis baths 
 and gymnastics make heavy demands on the heart, espe- 
 cially gymnastics, so that in pronounced arterio-sclerosis it 
 is better to avoid resistance exercises entirely. Gymnastics 
 are absolutely contra-indicated in all cases in which chronic 
 nephritis is present. Such patients are liable to violent 
 fluctuations of their vaso-motor tonus. In them the de- 
 mands on the heart can never be estimated beforehand with 
 any certainty. If, on the other hand, as often happens, 
 cardiac insufficiency is the primary disease and the kidney 
 affection is secondary to it, such patients may with advan- 
 tage be treated with baths and gymnastics. 
 
 ' ' Further, all patients to whom an acceleration of the blood- 
 stream is dangerous are naturally precluded from baths and 
 gymnastics, also persons who have had even a slight attack 
 of apoplexy, persons with distinct cerebral arterio-sclerosis, 
 and persons who have recently recovered from embolism. 
 If the condition of the brain improves and the state of the 
 heart renders bath treatment desirable, I advise for these 
 patients baths of medium or almost medium temperature 
 which do not contain carbonic acid gas, such as plain and 
 thermal brine baths. Finally, it is scarcely necessary to 
 emphasise the fact that the general condition of the patient 
 should be taken into consideration, and that those who, above 
 everything, require rest, especially neurasthenics, the over- 
 worked, the exhausted, and the very emaciated should not 
 be put through a severe course of baths or gymnastics, at 
 least at the beginning of the cure. 
 
 " If weakness of the heart occurs in a person who has led 
 a physically very active life, it is useless to expect benefit 
 from gymnastic exercises, when the much heavier work 
 required of the heart in his daily occupation has not averted
 
 6 GYMNASTICS FOR HEART AFFECTIONS 
 
 the occurrence of insufficiency. But if none of the contra- 
 indications already enumerated are present, and especially 
 if there is no contributory overstrain, we may well expect 
 good results in cases where the heart of a muscularly weak 
 person fails. Thus heart-weakness in a muscularly weak 
 but corpulent young person with no arterio-sclerosis is very 
 suitable for gymnastic treatment. In these cases we fre- 
 quently see most excellent results from strengthening the 
 heart by this means. 
 
 "Gymnastics may be more freely prescribed in the after- 
 treatment of cases in which the heart-weakness has ceased 
 to be active, than in the treatment of fresh attacks. In the 
 former careful gymnastic treatment is often a very good 
 introduction to more active bodily exercise, of course only 
 in persons without pronounced arterio-sclerosis, also more 
 especially in young people. 
 
 "The question may be asked whether there is any real 
 necessity for the physical methods of treatment, whether the 
 same results cannot be obtained more simply, and with at 
 least equal certainty, by means of drugs. I believe the 
 question cannot be answered in a word. The mode of 
 action of each is very different. Drugs enable the heart to 
 utilise more of its available strength. Whether by con- 
 tinued use they increase the sum total of the heart's strength 
 is not known. But baths and gymnastics we know, by the 
 way they influence the heart, increase its strength, just as 
 dumb-bell exercises increase the strength of the muscles of 
 the arm. There are cases in which drugs fail, as, for 
 example, in many forms of cardiac insufficiency occurring in 
 obese persons without any anatomical lesion of the heart, in 
 many obstinate dilatations of the right side of the heart from 
 mitral stenosis, and when there are lingering remains of 
 overstrain of the heart or of heart-weakness after infective 
 diseases, especially after articular rheumatism. In the first 
 of these gymnastic exercises and in the two last baths render 
 excellent service by increasing the strength of the heart 
 which is too weak to meet the demands upon it. 
 
 "Augmentation of the working capacity of these hearts
 
 INDICATIONS FOR AND AGAINST 7 
 
 can often only be effected by increasing their total strength. 
 As they work they are putting forth all their strength, but 
 that is not sufficient to meet the demands upon them till it is 
 proportionately increased. Drugs are powerless to extract 
 any more work out of these hearts. 
 
 "In consequence of their modes of action being different 
 there is no objection to prescribing baths and gymnastics in 
 conjunction with drugs. Under certain circumstances the 
 latter put the heart in a condition to derive benefit from the 
 former. 
 
 " A further question, specially raised by August Hoffmann, 
 is whether the results of the physical methods of treatment 
 are lasting. Objective statistics on the point are certainly 
 very desirable but beset with many difficulties. It is always 
 somewhat uncertain to judge from subjective impressions. 
 As far as that is possible, I can say from my own experience 
 that very satisfactory results can be obtained in this respect 
 when they are used in the restricted manner just indicated. 
 
 " I need hardly mention that all measures taken to 
 strengthen the heart, such as drugs, baths, and gymnastics, 
 can only be employed with prospect of success if its ordinary 
 work be lightened. This applies especially to physical 
 methods which make increased demands on the strength of 
 the heart and work directly in that way. These demands 
 may so easily augment the ordinary work of the heart that the 
 result may not be the hoped-for improvement, but in certain 
 circumstances direct injury to its strength by overstrain. 
 When drugs are given it is the general rule, and very 
 rightly so, to curtail the patient's work or to order complete 
 rest. By so doing the drugs make no increased demands on 
 the work of the heart, they only make more of its strength 
 active and its work improves with this increase of strength. 
 But it happens daily that patients with heart disease are 
 ordered carbonic-acid baths, gymnastics, or even the Terrain 
 cure without reducing their ordinary duties. That is very 
 undesirable. 
 
 " To carry out these methods properly the patient requires 
 more rest than he had formerly. The actual amount of rest
 
 8 GYMNASTICS FOR HEART AFFECTIONS 
 
 that should be taken depends on the condition of the patient. 
 Precise rules regarding it cannot be laid down, but it is 
 always better to order too much than to run the risk of over- 
 straining the heart. The necessity of resting the heart 
 holds good in ordering all therapeutic measures. For this 
 reason baths and gymnastics should not be prescribed 
 together till it is certain that the heart will react to the 
 additional demand on it in the manner desired. After each 
 bath and each gymnastic practice the patient must take 
 ample rest. It is necessary to be specially stringent in 
 ordering rest after overstrain and to persons suffering from 
 the results of overstrain. More or less extensive reduction 
 of the ordinary occupation must likewise be made in cases 
 of obesity with heart insufficiency. Reduction of bodily 
 weight is better effected by dietetic measures. In obesity, 
 moreover, it not infrequently happens that with greater rest, 
 and in certain circumstances with richer diet than formerly, 
 the patient to his surprise loses weight, sometimes very 
 rapidly, as the stronger action of the heart causes excretion 
 to take place of the surplus water previously retained in the 
 body, which in obesity may reach a very significant amount 
 without causing oedema."
 
 CHAPTER III 
 
 Medical Supervision Necessary Methods of Controlling the Effects of 
 Gymnastics on the Patient Observations on the Pulse. 
 
 THE principal thing in a gymnastic cure is the instruction 
 of the person who has to do the gymnastics. It should 
 at once be said that at the beginning of a gymnastic cure 
 medical supervision is absolutely necessary in affections of 
 the heart. It is only when a certain stage is reached and 
 the patient can go through certain gymnastic tasks without 
 any effort that he can dispense with medical supervision. 
 Even then it is always necessary for him now and again to 
 see his physician, so that the latter may determine whether 
 the gymnastic exercises which he is taking are suitable for 
 him, and modify them if necessary from actual examination 
 of the patient. In testing the effects of gymnastics from 
 the physician's point of view, the subjective symptoms of 
 the patient play an important part, and the patient who is 
 expecting much from gymnastics may deceive himself by 
 his hopefulness, especially at first. There are some persons 
 who are so hardy that they are hardly ever conscious of 
 slight variations in their state of health. Others again, and 
 these are the more numerous, are of a more nervous dis- 
 position, and. in their anxiety about their condition often 
 imagine themselves to be worse when they are not. With the 
 former the physician must be cautious and reserved, as they 
 are too ready to say to him, "Give me something more to 
 do, I can bear it." These patients are not always the least 
 affected, and are often dominated by an incredible optimism 
 which might very easily induce the unwary observer to do 
 
 9
 
 io GYMNASTICS FOR HEART AFFECTIONS 
 
 too much, and in this way harm to the patient might arise. 
 The latter, namely, the anxious, he must deal with often in 
 an entirely different manner, and show them, by objective 
 demonstrations, what they can do without injuring them- 
 selves, so as to encourage them to attempt exercises which 
 make greater demands on their strength, but are, in his 
 judgment, within their capacity. At the same time the 
 physician must be careful not to make the optimists 
 pessimists, and the anxious indiscreet. In describing ob- 
 jective symptoms it is always best to tell every patient who 
 is curable the absolute truth. The manner in which the 
 information is to be imparted to him is, naturally, a matter 
 of judgment and tact. 
 
 For observing the actual effects of gymnastics different 
 methods are now available, by the combined use of which 
 it is possible to get a clear indication of their action. The 
 readiest means of testing whether gymnastics are producing 
 any change in the action of the patient's heart are naturally 
 observations on the pulse. Exertion causes changes in the 
 pulse even in health. Exercises therefore which have been 
 prescribed for a patient should not be at once discarded 
 merely because they increase the rapidity of his pulse ; but 
 after the exercises are over it should fall very quickly to 
 normal. If the increased rapidity of the pulse continues 
 for some time after the exercises, it should undoubtedly be 
 regarded as an unfavourable symptom of the gymnastics. 
 The first criterion therefore is : if after the gymnastic 
 exercises the frequency of the pulse is relatively increased 
 beyond what it was before the exercises, and if after a short 
 rest it does not return to normal, the sign is unfavourable. 
 Of course excessive increase of the pulse-frequency should 
 never occur after the exercises ; thus a pulse of 80 per 
 minute before the exercises should not reach 130 or 140 
 after them. That would indicate too much had been done. 
 The proper ratio is shown in the three pulse-photograms,
 
 OQ
 
 OBSERVATIONS ON THE PULSE 13 
 
 Figs. A, B, and C. 1 These were taken from a patient in 
 whom a severe attack of endocarditis following influenza 
 had left great weakness of the heart. Under careful treat- 
 ment the patient improved so much that his pulse showed 
 the results indicated in the illustrations. The first pulse- 
 photogram (Fig. A) was taken before the gymnastic exer- 
 cises, the second (Fig. B) immediately after them, and the 
 third (Fig. C) after the exercises when the patient had rested 
 for ten minutes on a couch. Above the pulse-curve is a white 
 line, with small notches at intervals on its upper surface. 
 The distance from one notch to the other represents an 
 interval of five seconds of time. The first two figures show 
 that the pulse has been scarcely altered by the gymnastics, 
 and Fig. C shows a remarkably steady pulse. The patient 
 always felt fresh and well after going through all our 
 self-resistance gymnastics, and even maintained that these 
 exercises revived him when he felt languid. Two other 
 pulse-tracings, Figs. D and E, show how a pulse of irregular 
 and intermittent character, as seen in Fig. D, has changed 
 till it gave the pulse-curve of regular outline shown in 
 Fig. E. In addition to having valvular disease, this 
 patient also suffered to a slight extent from weakness of 
 the muscular walls of the heart. After food he very often 
 complained of a feeling of weight in the gastric and cardiac 
 regions, and had an intermittent pulse. On several occa- 
 sions it was found that flatulent distension of the stomach 
 occurred generally between half and three-quarters of an 
 hour after meals. Radiographs taken under these con- 
 ditions frequently showed the diaphragm to be in an 
 elevated position. At first massage of the stomach was 
 used with success for the flatulency. After the massage 
 the pulse-tracing ceased to be intermittent. At a later 
 period the same result was obtained from gymnastics.- The 
 
 1 Verhandlungen des Congresses fiir innern Medizin, 1907, p. 561. 
 - " Pulsaussetzen und Ma^enblahung-en. " Dr. Med. J. Hofmann. Wiener 
 Kleinc Wochettschrift, 1907, Nr. 34.
 
 i 4 GYMNASTICS FOR HEART AFFECTIONS 
 
 pulse-tracings figured were taken before and after gym- 
 nastics with resistance. Here then was a case where the 
 alterations in the heart were entirely due to encroachment 
 on its area through the diaphragm being forced upwards by 
 gastric distension. Naturally it would have been bad had 
 a reverse result been recorded in the pulse-tracings. The 
 occurrence after the gymnastics of arhythmia, which did not 
 previously exist, should make us stop the exercises at once or 
 defer them to a later period ; or, if it had been set up by the 
 greater demands of newly added exercises, to revert to the 
 previous ones requiring less effort. 
 
 The pulse should not, however, become too slow after 
 gymnastics. When the pulse is quick it is undoubtedly 
 a good sign if in a short time after the gymnastics it falls 
 below what it was before beginning them. As, for example, 
 when a pulse of 120 per minute rises during the gymnastics 
 to 130, and during the period of rest after them falls to 90 
 quiet beats. That this is a favourable sign will also be 
 indicated by the subjective feelings of the patient. On the 
 other hand, it should be regarded as a direct sign that gym- 
 nastics are producing an evil effect on the action of the heart 
 when, for example, a pulse of 80 per minute slows down 20 
 or 30 beats during the rest after the gymnastics. If in brady- 
 cardia, with a pulse varying from 50 to 60 per minute, 
 gymnastics have the effect of still further lowering the rate 
 of the pulse, they must be stopped at once. A pulse which 
 is usually too slow should become quicker after gymnastic 
 exercises or after a series of such exercises, but never slower, 
 while they should lower the rate of a quick pulse. If gym- 
 nastics do not produce the results just mentioned in each of 
 these conditions, then they are not suitable for the patient. 
 
 We must now briefly consider the influence of gymnastics 
 on the irregular pulse. We have often observed that an 
 irregular pulse does not become regular, although the 
 patient may assure us that the gymnastics are having a very
 
 MEDICAL SUPERVISION NECESSARY 17 
 
 favourable influence on his subjective sensations and condi- 
 tion. Here we are confronted with the want of a proper test 
 to show us by the feel of the pulse the effects of gymnastics. 
 Certainly with the finger we can, by practice, determine 
 whether a pulse has become stronger and whether from 
 being hard it has become soft, which would be good signs ; 
 and with the finger we can also detect bad signs, such as a 
 change from a full and strong pulse to a weak and thread- 
 like one. But, in the case of a very irregular pulse, palpa- 
 tion fails to help us to arrive at a discriminative judgment. 
 We have therefore to employ another method, which is so 
 important that we cannot dispense with it even in patients 
 whose pulses are not irregular, namely observation of the 
 blood-pressure.
 
 CHAPTER IV 
 
 Testing the Effects of Gymnastics by Observations on Blood-pressure, 
 Auscultation, Percussion, Rontgcn Rays. 
 
 IN making researches on blood-pressure after gymnastic 
 exercises, we must always take care that the controls are 
 made under similar external conditions ; this applies also to 
 observations on the pulse. We proceed thus : After a 
 short rest in the horizontal position the blood-pressure is 
 determined by Riva-Rocci's method before the exercises. 
 Certain definite work is then done, and immediately after- 
 wards the blood-pressure is tested in a resting position as 
 before. The patient then does some more exercises, and at 
 short intervals the blood-pressure is tested till the same 
 pressure is shown as obtained before the gymnastics were 
 begun. Great care must be taken that the Riva-Rocci 
 manchette, or preferably the broad modification of it by 
 Recklinghausen, is always applied in the same way, so as to 
 eliminate as far as possible errors of variation. It must 
 always be of the same breadth and be put on the same part 
 of the upper arm ; it is also desirable to have a centimetre 
 scale marked upon it so as to facilitate its being drawn in to 
 the same point each time. After a definite amount of work 
 has been done the blood-pressure will show one or other of 
 the following possible conditions : 
 
 1. The blood-pressure may remain unaltered. 
 
 2. The blood-pressure may first rise and then fall to the 
 normal. 1 
 
 3. The blood-pressure may first fall and then rise to the 
 normal. 
 
 1 The normal is regarded here as the blood-pressure before any work has 
 been done. 
 
 18
 
 TESTING THE EFFECTS 19 
 
 4. The increased blood-pressure may fall below the normal 
 before it returns to normal. 
 
 5. The lowered blood-pressure may rise above the normal 
 before it returns to normal. 
 
 6. The increased blood-pressure may sink below and never 
 reach the normal. 
 
 7. The lowered blood-pressure may remain under the 
 normal. 
 
 8. The lowered blood-pressure may rise above the normal 
 and remain so. 
 
 9. The increased blood-pressure may remain above the 
 normal. 
 
 The time during which these variations of the blood- 
 pressure should be observed is, in our opinion, ten 
 minutes. 
 
 If the blood-pressure does not alter (i), then we may 
 rightly conclude that the exercises are doing the patient no 
 harm, and that they may be continued and increased. 
 
 (2) If the blood-pressure is raised it is not a bad sign if 
 the rise be not too sudden. Even in healthy hearts we find 
 the blood-pressure increased with exercise, but afterwards it 
 falls very rapidly to normal. This is an important point in 
 all cases of increased blood-pressure. A moderate rise and 
 a quick return to the normal are favourable signs. 
 
 (3) A lower blood-pressure after gymnastic work than 
 before it is not necessarily a bad sign, provided the blood- 
 pressure again rises quickly to the normal during rest. A 
 fall in the blood-pressure after severe exercise may also be 
 observed in healthy persons, and is brought about by the 
 action of the nervus depressor causing dilatation of the 
 cutaneous blood vessels, and so regulating the flow of blood 
 from the aorta where the pressure is highest. But soon after 
 exercise the blood-pressure rises again to the normal, 
 because during rest the increased activity of the heart 
 diminishes very rapidly, the high blood-pressure in the aorta
 
 20 GYMNASTICS FOR HEART AFFECTIONS 
 
 drops, and simultaneously the action of the nervus depressor 1 
 which has caused the dilatation of the cutaneous vascular 
 system ceases. /Thereupon the latter immediately contracts, 
 the transverse diameter of the blood vessels becomes smaller 
 and the blood-pressure rises and may, without any bad 
 results, even exceed the normal for a short time (5). It is 
 different, however, if during rest after exercise the blood- 
 pressure remains for a long time below the normal. Then 
 we have feeble working as a result of fatigue occurring in a 
 weak heart. When the blood-pressure rises after exercises 
 and remains above normal (8), we recognise in this continued 
 secondary elevation of the blood-pressure Moritz's symptom 
 of "strain and exhaustion " which indicates that too much has 
 been done. We must also regard as a sign of strain and 
 exhaustion the fall to below the normal of a blood-pressure 
 which has risen to above the normal (4), and by the amount 
 of rise, the extent of the fall, and the time taken to return to 
 the normal, we form an estimate of the unfavourable effect 
 and overstrain which has resulted from doing too much. 
 Finally, if the blood-pressure rises too violently and remains 
 for a long time above the normal (9), it indicates overstrain, 
 after which we must always fear the effect of exhaustion. 
 
 Examination of the heart by means of auscultation and 
 percussion, and also by X-rays, should not be omitted 
 whether the results of gymnastics as shown by the pulse and 
 blood-pressure are good or bad. Regarding percussion, we 
 often find when the pulse and blood-pressure show unfavour- 
 able signs after gymnastics, that the area of heart dulness is 
 broader than it was previously; while, on the other hand, an 
 orthodiagram shows no alteration in the shadow of the heart. 
 It was this broadening which in former times frequently led 
 physicians' to diagnose acute dilatation of the heart. Fortun- 
 ately that is not the case, or it would be very serious, as 
 
 1 According to Koster and Tscherm;ik, the nervus depressor ends in I he- 
 aorta it>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. 
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 Remedial gymnast 1' 
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