In advanced cases of valvular incompetence, especially in the aortic valves, some doctors are so much impressed by the quick bounding pulse, by the fear of haemorrhage, etc., that they are opposed to any other exercise than that necessary in daily life, or at least all therapeutic exercise other than walks on level ground. On the other hand, they are perhaps more inclined with stenosis to help the compensatory hypertrophy behind the stenosis, in order to lessen the stasis behind it and increase the lessened blood flow on the other side. Other doctors, and among these Oertel, hold an entirely opposite view; they are more inclined to use the terrain-cure in cases of incompetence than in cases of valvular stenosis, and are especially afraid of prescribing too much work for the heart when there is stenosis of an auriculo-ventricular opening and when there is hypertrophy due to excessive work in the normally thin walls of the auricle of the heart.

Valvular incompetence and stenosis are too intimately connected and too often combined for us to make any great difference in the treatment of each. Neither do we in Sweden make any difference in our mechano-therapeutic treatment. As soon as we want to bring about or strengthen a compensatory hypertrophy, or, in other words, as soon as anything can be gained by exercising the heart, which is the case in all slight instances of valvular stenosis or incompetence, but not so in advanced cases of cardiac incompetence, we use gymnastics. It is well to repeat that we ought to prescribe the terrain-cure in all suitable cases where the patient has the opportunity of taking it, and where constant supervision is unnecessary. In the more severe cases we accentuate our prohibition of all over-fatigue, and allow only horizontal or quite gently inclined walks, and give emphatic warnings against any exercise so violent as to cause dyspnoea.

When it is not possible to use the terrain-cure the patient is sent to a medical gymnast or, if possible, to a Zander institute. In the institutes in Sweden doctors send their patients for pure mitral stenosis as well as for pure incompetence, or for both combined.

Dilatation, fatty heart, and arteriosclerosis place the doctor who firmly believes in gymnastic treatment for the heart in a quandary as to his choice of treatment.

Among the definite contra-indications to gymnastics we unanimously reckon sudden dilatation, which is very seldom seen as the result of over-strain caused by too strong physical exercise, apart from definite organic changes in the heart. This sudden dilatation is really a partial rupture, and is accompanied by acute symptoms of incompetence, etc., and is very liable to end fatally. Just as abstinence from violent exercise is the most important prophylactic measure, so is rest the most important means of treatment, and only after recovery can very careful gymnastics be used.

But in cases of slowly developing dilatation the case is altered on account of the increased intracardiac pressure and the weakness of the walls of the heart due to chlorosis, anaemia, or other prolonged and severe illness, when the cavity of the heart is enlarged, the walls being relatively or absolutely thin but otherwise healthy. In these cases nature strives constantly for hypertrophy, produced by the increased work of the heart in systole due to its increased contents. This hypertrophy, which is compensatory to dilatation and is very desirable, is hindered by a sedentary life, but it can be encouraged by a suitable mode of living with a moderate amount of exercise. But the dangers of over-strain are obvious, and a close consideration of the physical signs and of the symptoms, on which we lay great importance, and also of the intellectual and psychological characteristics of the patient, must decide if we should recommend a terrain-cure on horizontal and perhaps gradually on slanting ground, or if we should prescribe a gymnastic treatment at a Zander institute or elsewhere.

By the expression fatty heart we understand in Sweden two different conditions - either the extensive fatty infiltration in the connective tissues of the heart, or the real fatty degeneration of the protoplasm of the cardiac muscle fibres.

Gymnastics, especially the terrain-cure, gives excellent results in cases of fatty heart in obese patients, when the heart is merely mechanically hampered in its work by the extensive masses of fat in its connective tissue, but the muscle fibres, apart from any slight fatty degeneration resulting from the mechanical pressure of these masses, are for the most part healthy and normal in function.

Early fatty degeneration can also be counteracted in its first stages by active gymnastics, either in the form of systematic walks or by Ling's, Zander's, or other system.

But advanced fatty degeneration of the heart contra-indicates active gymnastics. The heart should not be treated by strong active exercises in the following instances : - After severe febrile (and other) illnesses; towards the end of prolonged valvular disease; in cases of abuse of tobacco and alcohol; when the blood supply is diminished or the blood insufficiently oxygenated, or when some harmful substance (as alcohol in drunkards, β-oxybutyric acid in diabetes) is present in the blood; or (in cases of valvular disease) when there is difficulty in the flow of blood and lymph from the heart; when any of these conditions have produced extensive chemical changes in the muscle fibres - in other words, in all cases of marked loss of functional power and in high degrees of incompetence.

It is in such instances that gymnastic institutes are of use with passive exercises and massage, the former in the form of arm-rolling, leg-rolling, circle-turning, chest-lifting, etc., the latter in the* form of arm-kneading, leg-kneading, abdominal kneading, chest-clapping, etc. This treatment gives no extra work for the heart, but by certain movements and manipulations aims at assisting the work of the heart, diminishing stasis, accelerating the circulation, relieving dyspnoea, and partly in a psychic way, mitigating the final sufferings of the patient. (See also what is said by Dr. Arvedson and Dr. Zander on the same subject.)