Doubtful cases where one fears that the terrain-cure, in which the patient necessarily is left to his own judgment, might cause paralysis or rupture of the heart, are suitable for treatment in medico-mechanical institutes and by medical gymnasts. In these cases, besides passive exercises and massage, one uses careful resistance movements for the trunk and limbs, especially the lower extremities, and, particularly in Germany, the slow self-resisted exercises.

To regard arteriosclerosis without exception as a contra-indication to gymnastics is as unjustifiable as it is to exclude from gymnastics most people above the age of sixty. Only the severe form of arteriosclerosis need be considered a contra-indication. Among the patients in the Zander institutes there is a large number of cases, especially men, suffering in some degree from arterio-sclerosis and its consequences, in which the heart can still be exercised, but for which the terrain-cure is considered too dangerous and constant supervision is necessary. In a great many slight cases the terrain-cure may be prescribed with advantage. In several cases of unmistakable arterio-sclerosis, when the functions of the heart were still fairly good and when most of my colleagues preferred using Zander's Institute, I have prescribed a terrain-cure. One must in such cases rely on the patient's own judgment and the care he takes of himself and limit his walks to horizontal or slightly-sloping ground. By the nature of the case the therapeutic results are limited if arteriosclerosis is somewhat advanced, but are often sufficiently good to satisfy both doctor and patient.

In advanced cases of arteriosclerosis the terrain-cure is certainly out of the question, particularly when the disease affects the coronary arteries. We have often in such instances a marked fatty degeneration of the heart, which contra-indicates any treatment by exercise. Along with this in certain cases we find a definite blocking of the smaller arteries of the heart, and in consequence, often near the apex, numerous and widely-scattered softened patches (Ziegler's myomalacia). Or in consequence of this softening we find fibrous myocardiac changes, consisting of diffusely-scattered small solid masses of connective tissue, which occasionally cause real aneurysm of the heart and which are easily ruptured by increased intracardiac pressure. These conditions often give rise only to slight physical symptoms, although any exercise beyond the ordinary requirements of daily life is dangerous. This knowledge makes the cautious physician particularly careful and thorough in his examination, before he decides to allow a patient suffering from advanced arterio-sclerosis to undergo any treatment which necessitates work for the heart.

When one aims at strengthening the heart one must make use of other means besides gymnastics to promote hypertrophy, and exclude all influences leading to degeneration of heart muscle. Dietetic rules are therefore of the greatest importance.

In the first place one must forbid all abuse, and preferably all use of, tobacco and alcohol. Both are important, and tobacco is often as great a hindrance to a successful result as alcohol, none the less so because many more doctors use tobacco than spirits to excess and cannot, therefore, take an objective view of the subject. We all know, however, how much worse the prognosis is for an ardent smoker than for a non-smoker when the strength of the heart is in question, e.g., in pneumonia, and "the smoker's heart" includes a "museum" of pathological anatomical changes. It is always easier for excessive smokers to abstain completely than to arrive at moderation, and the sudden breaking of the bad habit produces no inconvenience other than a marked degree of constipation.

One must be more cautious in making a sudden break in the patient's habits in regard to alcohol. But during the period of breaking off, a larger daily portion of alcohol should never be given than the amount corresponding to \ gram of absolute alcohol per kilo of body weight, and anything over \ gram per kilo of body weight in twenty-four hours is certainly harmful in the long run.

In every treatment which aims at strengthening the heart there should be an ample supply of albuminous material. In the cases complicated by obesity, fat and carbohydrates should be moderately diminished; but one must remember that in all cases of heart weakness these diminutions must be specially moderate, and that the loss of flesh which a fat person undergoes by means of increased exercise, always within the fatigue limit, is more beneficial than that obtained by extensive dietetic limitations. Oertel's system allows 156 to 170 grams of protein, 22 to 43 grams of fat, and 71 to 114 grams of carbohydrate (see Treatment of Obesity).

When the frequent blood-letting of former times in heart affections was given up, and in its place it was attempted by diminishing the supply of fluid to counteract the disturbance in hydrostatic equilibrium and to bring into equilibrium the scarcity of blood in the arteries of the systemic circulation, with the corresponding overfulness in the pulmonary circulation and in the systemic veins, there was a tendency to regrettable extremes, due chiefly to German doctors and writers. AEsthetic reasons often induced these extremes in stout women patients. People not only ceased to follow the general instinct of drinking water at mealtimes; they often limited to much below normal the daily quantity of water taken. The results made themselves evident in a weak condition of the heart and nervous system, from which the patients occasionally did not recover, in loss of appetite and dyspeptic symptoms, and in extreme cases in sudden fatal termination from inflammation of the kidneys, even when the kidneys were healthy at the beginning of the treatment. (When they are unhealthy an intelligent doctor would hardly agree to the limitation of fluid below the normal.) In many cases after such treatment, ill-advised or badly carried out, I have seen gall-stones or renal calculi develop, but whether post hoc or propter hoc I admit could not be settled. One must also take for granted that this extreme limitation of fluid is injurious in gout or a tendency thereto.