To fulfil these indications medico-mechanical gymnastics makes use of various passive and active exercises (E6, C6, E7, C7, C8, Cl, C2, C5) already mentioned. Rhythmical manual compression of the chest, preferably performed by the physician, may with advantage be added to this prescription.

The particular exercise chosen must be determined by the needs of each case. The cardinal rule in treatment of all heart disease must be borne in mind - that the functional diagnosis of the case guides the treatment rather than the anatomical diagnosis. One has to think of the degree of circulatory disturbance rather than of the exact form of valvular defect, or the kind of myocarditis which has produced it. It is nevertheless true that certain anatomical conditions are of importance in the treatment. Widespread arterio-sclerosis, coronary sclerosis, aortic aneurism, for example, limit definitely the value of movement. It is dangerous to overstep this limit. All sudden and severe muscular exertion must be avoided, even when the patient is not conscious of weakness. Apart from cases such as these we may lay down the broad general rule that alterations in the functional and reactive power of the heart decide the treatment.

It seems to me conducive to clearness to give here a series of gymnastic tables of a strength graduated according to the reactive power of the heart, beginning with a case where only the gentlest passive movements can be used, going on to a case where the heart, either from the beginning of treatment or by means of the graduated gymnastic training, has such good power of reaction that the treatment approaches an ordinary gymnastic table.

I must, however, first mention two movements which on account of their peculiar efficacy deserve special notice and should never be omitted from any heart table.

The first is E6, Chest-expansion; the second is Jl, Arm-sawing (light kneading). The former acts as a passive respiratory movement, assisting circulation to a large extent, while at the same time it does not strain the patient in any way. If done sufficiently gently at the beginning it is indicated in every case which is in a condition to attend a gymnastic institute, and very few fail to find considerable relief as a result. Arm-sawing is also a movement which works almost like magic. It is not unusual for patients who come to the institute with palpitation, shortness of breath, and sternal pains to find all these disappear under the influence of Jl. These two movements, along with Back- and Heart-tremble-shakings, are the triumph of gymnastics, and seldom fail in their effects. The last mentioned are specially indicated in the case of quick and irregular pulse and of dilatation of the heart (in this case they must be done with the greatest care).

In conclusion I give a series of prescriptions which may serve as an example of a progressive scale. I would point out, however, that special conditions in a particular patient may necessitate additions or alterations which cannot be considered here, where we only aim at giving a general idea of the treatment of heart disease itself. Only the exercises are mentioned, not the numbers, which are included in a complete table showing the position or amount of resistance, which must be decided for each patient separately. At which step in the scale one should begin for a particular patient is also a matter for the individual case, and must be decided by careful observation of his power of reaction. A criterion as to the suitability of the treatment is that the patient should feel refreshed after the treatment and less tired than when he began.