The medico-mechanical treatment of heart disease is, like the manual, founded partly on physiology and partly on experience. For the sake of clearness and to avoid repetition I will only mention the chief points to consider in ordering gymnastic treatment for a heart patient, in order to point out under each heading the corresponding medico-mechanical movements.

The various ways in which the gymnast tries to alleviate the condition of the patient's heart can be grouped under four principal headings: -

(1) Aiding the Circulation of the Blood and Lymph.

This helps the work of the heart, improves nutrition of the tissues, and gets rid of oedema. The slowing of the blood stream is the main cause of all pathological disturbances in heart cases. An increase of its speed is therefore of great importance. By means of gymnastics this can be effected : -

(a) In a purely mechanical way by movements and manipulations which produce a rhythmical compression with alternate passive and active dilatation of the veins, whereby the blood is pumped towards the heart, directed by valves.

(b) In a reflex way by the use of active movements, whereby the blood stream in the working muscles and the blood vessels leading to them dilate and resistance is thus lessened.

The medico-mechanical movements to fulfil these indications are as follows : - '■

Arm-kneading (Jl), Leg-kneading (J3), Leg-hacking (G3); these manipulations have a purely passive effect through the rhythmical compression of the muscles of the arm and leg, by which the blood and lymph are driven on in a centripetal direction.

Foot-stroking (J4) and Foot-shaking (Fl) cause primarily or secondarily a dilatation, and thus lower the resistance offered in the blood vessels of the foot and leg.

Hand-rolling (A7b), Passive Hand-flexion and -extension (E2), Passive Hand-adduction and -abduction (E3), Arm-rolling (A7a), Arm-alternate-rotation (A8b), Leg-rolling (E5), Passive "Cycling " (B7), Passive Foot-flexion and -extension (Bll), Foot-rolling (B12); all these exercises are more or less passive, and help the circulation by means of the co-operation between the fasciae and the valves of the veins (see chapter on Physiology).

Passive and Active Trunk-rotations (E7, C7, C8), Pelvis-tilting (Dl) and Trunk-rolling (D2 and D3), assist the abdominal circulation by the rhythmical compression of the viscera. Abdominal-circular-stroking (J6) and Abdominal-kneading (H1) act almost in the same way.

Trunk-raising (C2 and C5), Trunk-side-flexion (C6), and Chest-expansion (E6) are respiratory movements - the first two active, the third purely passive in character. They assist the systemic and pulmonary circulation, of which more will be said.

Finally we may here mention some active movements for the exercise of muscles as such. They have the same effect as the movements in Section (3), and will be there specified.

(2) The Stimulation and Regulation of the Heart's Action by Direct Influence on it.

This is due to the empirical fact that certain local procedures have been shown to influence the action of the heart. Vibration and hacking over the region of the heart (Fl and Gl) have a regulating influence on the rhythm and frequency of its beat. Back-vibration (Fl) (between the shoulder-blades) has a slowing influence almost immediately on a too rapid heart-beat. In cases of a very irritable heart, especially when it is dilated, these methods, especially heart-vibration, cause somewhat unpleasant sensations (a feeling of oppression, giddiness, etc.). This is not a contraindication for treatment, which should be discontinued for a time only, until the patient has become used to it by gentle and brief treatment; in quite a short time it will be found effectual.

(3) The Strengthening of a Weakened Heart.

By systematically increased active movements, which may be termed "progressive training" of the heart muscle. This indication, which can only be carried out if the heart has some reserve force, is common to gymnastics and the "Terrain-cure." The advantage of the gymnastic method is that it can be begun with much weaker active movements than walking on level ground. It is easy to increase the exercises slowly and gradually until the maximum strength of the patient is reached, and it is just in this choice of exercises that the skill of the gymnast lies. The strength of a movement depends on two things : first, the amount of resistance used, and, secondly, the size of the muscle groups brought into action. The following is a list of exercises which are used for this purpose (it increases in progression from the weakest to the strongest) : -

Arm movements : Hand-rolling (A7b), Hand-flexion-extension (All), Arm-rotation (A8b), Elbow-extension (AlO), Elbow-flexion (A9), Arm-rotation (A8a), Double-arm-carrying -forward and -backward (A5 and A6).

Leg movements : Foot-rolling (B12), Leg-rotation (B8), Knee-flexion and -extension (B9 and B10), Hip-knee-extension (B4), Leg-adduction (B5), Hip-knee-flexion (B3), Leg-abduction (B6).

Trunk movements : Sitting Trunk-extension (C2), Trunk-side-flexion (C6), Pelvis-rotation (C8), Trunk-turning (C7), Sitting Trunk-flexion-forward (Cl), Standing Trunk-extension (C5).

(4) Treatment of other Organs the Condition of which directly Influences the Action of the Heart.

This section deals partly with the digestive system, partly with the respiratory system. Such conditions as chronic constipation and accumulations of gas in the stomach and colon may have a very hampering effect on the work of the heart, and are treated very successfully by medical gymnastics, the local manipulations used being Hacking, Vibration, Kneading, and Stroking (Fl, Gl, H1, J6).

It also refers to the respiratory system, which is perhaps even more important. It is easy to understand the important relation existing between the respiratory organs and the heart apart from the pulmonary circulation, if one remembers the mechanical part the respiration plays in circulation. During inspiration the blood is drawn in through the large veins towards the heart; during expiration it is pressed out into the arteries. Upon this depends, on the one hand, the direct effect respiratory gymnastic movements exercise on the circulation, mentioned under (1), on the other hand, the great importance of mobility of the thorax. It may well be a question whether many of the heart symptoms, dyspnoea, palpita-tion on exertion, which commonly accompany old age, depend upon the rigidity of the chest, which is so common, and which hampers its movements and so impedes respiration. In favour of this view is the obvious effect produced by improving the mobility of the chest. In heart massage, which is considered by some gymnasts of very great value, a forced rhythmical compression of the chest is used, the effect of which is probably due to the mobility of the chest thus gradually produced rather than to any direct influence on the heart.