Medical gymnastics includes movements which vary from the most careful passive movements in a single joint (for contractions in the same) to the extensive severe marching of "terrain cures" (for obesity). With a reminder of this and of the need for discrimination in estimating the value of the contra-indications, which must be left to the reader, I introduce what follows.

We must first notice three general conditions and diseases which often contra-indicate gymnastics, especially all extensive movements : - severe diseases of various kinds accompanied by great weakness, all fevers, all acute inflammations, particularly in the parts of the body taking part in the movements.

It goes without saying that the extremely exhausted patient, for example, a case of Bright's disease in the last stage, a very anaemic person, an advanced case of diabetes, ought not to be subjected to (medical) gymnastic treatment.

The febrile patient is also excluded from such treatment as a rule, partly on account of his mental sensitiveness and need of absolute quiet, partly because extensive physical exercise causes an increase of temperature.

Acute inflammation in its various forms contra-indicates movements in that part, because these increase hyperaemia and thus help to keep up the inflammation. In all times rest has therefore been considered an excellent "antiphlogistic." All extensive purulent processes are absolute contra-indications, and even all purely serous ones. In a recently sprained ankle modern treatment, to be complete, consists of ice-bags, raised position, effleurage, and complete rest until the more acute stage of inflammation is over. This applies also to all extensive acute catarrhs, e.g., gastro-enteritis.

On the other hand, inflammations which are quite chronic do not contra-indicate gymnastics. We do not place chronic rheumatic groups of muscles at rest, nor forbid movements in the joints where fluid is present, or with the common localised infiltrations in the capsule (known in Sweden as "capsulitis"), dry crepitating arthritis, chronic catarrh in the alimentary canal or air passages, etc.

Just as many morbid conditions and processes in the circulatory organs, especially in the heart, are beneficially affected by gymnastics, so there are other allied diseases of the heart and blood vessels in which extensive or strong movements are harmful, perhaps even immediately dangerous to life. Many of these conditions are hard to diagnose, or at least to estimate at their proper value, and it is one of the most difficult duties of the practitioner to judge rightly in these cases, and to state in a special case whether all gymnastics is contra-indicated or whether, and in what form, it should be used.

One may assert that all acute heart affections, serous, "plastic," ulcerous and purulent, endo- and peri- carditic processes, and even acute neuroses of the heart, forbid all gymnastics.

One may further assert that in extreme cases of morbid change resulting from such processes there is no prospect of improving the heart's action by means of active gymnastics, and that all active movements, beyond those which are necessary for a daily life as quiet and methodical as possible, carry with them the danger of rupture, haemorrhage, renewed inflammation, emboli, etc.

Among such conditions we include extreme degrees of valvular disease, extensive adhesions between the visceral and parietal layers of the pericardium, the latest stages of fatty degeneration of heart muscle, changes in the myocardium due to severe pericarditis and endocarditis, or long-continued febrile disease, before nature's repairing work is completed, advanced arteriosclerosis, especially in the coronary arteries, above all, large or small necrotic areas, depending upon the latter, generally found near the heart's apex (Ziegler's myomalacia), also aneurism of the heart.

The only medical gymnastics which can be considered in these conditions are passive movements which specially help the circulation and more especially the return of the systemic venous blood to the heart, and moderate walking on level ground.

For the rest I would refer to my account of the treatment of heart disease by "terrain cures" in the latter part of this book.

In pure neuroses of the heart we generally exclude all movements which greatly increase the heart's action, that is to say, all brisk and extensive active movements. One must, however, take this contra-indication with great discrimination. If a heart neurosis has been produced by excessive physical exercise, we forbid those special exercises. But those leading sedentary lives who suffer from palpitation of the heart, with irregular pulse and other marked and troublesome, though often subjective, symptoms, often feel much better or are completely cured by physical exercise, which should be taken in such cases during those hours when the heart is regular. Most of these patients suffer from their symptoms only during part of the day or night. I have repeatedly had good results in such cases from systematic "terrain cures." There is scarcely anything in the way of exercise which more often produces neuroses of the heart than excessive cycling. On the other hand, a distinguished nerve specialist among my Swedish colleagues maintains that he is free from palpitation whenever he takes a vigorous cycle ride daily.

Among heart neuroses I include Basedow's disease, and especially those cases of partially developed Basedow's disease which we see much oftener than the developed disease, and in which the tachycardia and nervous symptoms without exophthalmos lead us to discover the only slightly apparent swelling of the thyroid gland. In these cases no movement with the slightest strain is permissible.

All conditions of the vascular system in which there is danger of haemorrhage contra-indicatc extensive movements which raise blood pressure in the vessels. Apart from arterio-sclerosis I am thinking now of "open" ulcerous processes in the lungs in phthisis, in gastric and duodenal ulcer, etc. To order gymnastics in a case of definite aneurism should be a matter of legal responsibility. In regard to varicose veins, see the chapter on "Terrain Cures."

All conditions of the vascular system in which there is danger of embolus are a decided warning against brisk or prolonged movements, and we are always anxious in cases of venous thrombosis to ensure the most complete rest possible for the patient until it has "consolidated."

Neuro-muscular affections associated with hypcrtonicity, i.e., with a continuous morbid increase of muscular activity, in the form of tonic or clonic cramp, spasm, tremor, etc., contra-indicate movements and indicate resistance treatment. On this subject views differ widely. In chorea the complete resistance treatment by means of immobilisation has its devoted adherents. In the coordination occupation neuroses we ought undoubtedly to exclude all gymnastics, and in mechano-therapeutics make use only of massage. On the other hand, there arc many doctors and more "specialists" who would include self-resisted movements, in which the patient tries to regain control by performing the movement with great attention and quite slowly. Meanwhile it cannot be far from the truth to assert that all morbid conditions which are the result of overstrain or produce strain on movement should at first be treated by rest, especially of the directly over-strained parts of the motor apparatus, and from those movements which have caused the over-strain. For the rest I would refer to what is said above on over-strain; all the pathological conditions arising from it contra-indicate active gymnastics.

-.

The motor apparatus in order to be exercised must be free from some of the more important changes and conditions, most of which preclude gymnastics on account of acute inflammation, as already mentioned, or on account of the necessity of immobilisation for healing to take place. Recent fractures or dislocations, sprains and bruises, osteomyelitis, and tumours of bone, prevent physical exercises.

Gymnastics is contra-indicated by various conditions and processes which also contra-indicate massage.

Strong or extensive movements are dangerous in certain conditions in the abdominal cavity. Apart from gastric or duodenal ulcer, which have already been mentioned as causing danger of haemorrhage, ovarian cysts and other tumours, hydatid of the liver, hernia, etc., must also be mentioned.

Stone in the pelvis of the kidney or bladder, as well as large stones in the gall-bladder, contra-indicate violent exercises.

The same is the case with pregnancy.

Certain poisons are absorbed more quickly and produce more severe effects during movement than during rest, whether they are taken in by the mouth or (as in snake-bite) by the skin.

Physical exercises, owing to their exciting influence, are contra-indicated in the various forms of psychic exaltation.