Under the influence of the terrain-cure, aeration of the lungs, as we have seen (page 101), is greatly increased by increase in the amount of the inspired and expired air, and the muscles of inspiration and expiration are exercised in the same way as other skeletal muscles by systematic work.

Besides the effect of the terrain-cure on the circulation and general nutrition, it has an influence on the chest and the whole respiratory apparatus, which obviously tends to counteract the development of the type of chest called "poitrinaire" thin-walled and flat, which we see in the predestined victims of tuberculosis. There is scarcely a physician who will not recognise the truth of these facts. But even in these days, when we establish at great expense here and there in the country sanatoria for tubercular patients, it is nevertheless a rare exception for any doctor to make use of the many places to be found in the Scandinavian peninsula where suitable sloping ground, pine woods, and high altitude in combination invite him, not only to therapeutic, but to prophylactic activity against our most deadly disease. I think we commit in this way a terrible sin of omission against thousands of the nation's children with phthisical heredity and predisposition, whose health and power of resistance to this deadly disease could be improved by annual holidays with hill-climbing during their period of growth. It is certain that the development of the disease requires other conditions besides the existence of tubercle bacilli. In these cases terrain-cures accomplish so much more than medical gymnastics that I think the latter may be ignored.

The same holds good in cases of catarrh of the air passages. Laryngitis, tracheitis, and bronchitis are favourably influenced by terrain-cures, especially in mountainous districts clad with pine trees, high above sea level. It is not only the dry ozone-laden mountain air, tree from bacteria, which is of so much therapeutic value in these cases. Amongst other ways in which the terrain-cure counteracts the tubercular tendency is that of causing hyperaemia of the lungs; the more complete aeration of the lungs caused by the deeper respiration consequent on hill-climbing has also an important effect. These benefits, amongst others, may justly be credited to the terrain-cure.

Doctors who have had the opportunity of observing the effect of the cures in such health resorts in Austria, Switzerland, Germany, and the Scandinavian peninsula, or in Colorado in North America, which by the character of their terrain are naturally associated with the terrain-cure, have had good opportunity of verifying its strong curative effect even on the ill-omened catarrh of the apex. Many such patients still survive whose death from consumption might have been expected about ten years previously. Where excavating processes have developed one must, of course, take into consideration the increased danger of bleeding produced by strong active exercise.

In emphysema, as we know from Hanke, expiration in rarefied air is beneficial; inspiration of rarefied air, on the contrary, increases the pulmonary incompetence and dyspnoea. I think, therefore, without considering that I have the right to speak as an expert, that if an emphysematous patient for other reasons requires the terrain-cure, or tries it for his emphysema, it should be carried out preferably at a moderate height above the sea level. In regard to the special forms of asthma, the results of mountain walks are so uncertain and capricious that I feel unable to give a definite and detailed opinion.

Children suffering from whooping-cough who are treated by the terrain-cure, either before or after convalescence, derive great benefit both as to the disease itself and in regard to its sequela?. This, however, holds good for change of air in general.

The treatment of the results of inflammatory processes in the lungs and pleura by active and passive gymnastics is satisfactory. Here we have to deal with a condition of atelectasis in the lungs, with pleural exudations and adhesions between the visceral and parietal, especially the costal, layers, and, lastly, with deformities of the chest produced by the prolonged presence of large pleural exudations. Amongst these deformities .we must specially consider the difference between the lateral halves of the thorax following Estlander's operation of resection of ribs for empyema.

As soon as we have double-sided processes and conditions to deal with, the terrain-cure, besides being enjoyable in itself, excels all other kinds of gymnastics; and a minute comparison between the respective results of the terrain-cure and of other systems can only redound to the credit of the former.

But when we have one-sided conditions to consider we must recognise the essential advantage of other gymnastic systems, especially of Ling's manual system, over the terrain-cure in that it can by special movements pay special attention to the affected side and can work strongly and exclusively upon that, while the terrain-cure only acts by influencing the whole chest by the larger respiratory movements. I have the less reason for entering upon a comparison between manual gymnastics and the terrain-cure, since, although I have observed the results of both systems, I have not myself carried out the manual treatment, nor have I investigated by suitable measurements of the chest and of its vital capacity the results which I have obtained time and again with terrain-cures alter reabsorption of long-continued, large serous or sero-fibrinous pleuritic effusions, and even in one or two cases after resection of ribs for empyema. On the other hand, I can say from my own experience that even in these cases one can obtain surprisingly good results from terrain-cures intelligently conducted.

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Just as one can influence the heart by means of different forms of tapotement on the chest and can produce slowing of the pulse by means of the vagus reflex, so one can also by suitable manipulations diminish dyspnoea due to cardiac or pulmonary incompetence, in the way I have described (page 50), by leading to more complete oxygenation of the blood and the reduction of carbonic acid.

I assume the possibility of aiding the reabsorption of exudations within the chest by different forms of tapotement, especially by vibrations, although I have not myself made use of such a procedure or heard any other opinion on the subject.

As Oertel massaged the heart, so has Hunerfauth massaged pleural exudations after the cessation of the inflammatory process. So far as one can gather from the not very clear description, Hunerfauth performs this massage, when inflammatory products are present on both sides, by manually compressing the thorax on alternate sides in order to increase the pressure between the costal and pulmonary pleura, especially during inspiration. In the case of one-sided inflammatory products he massages "with the chest relaxed," and again during inspiration with one hand on the chest over the exudation, while the other hand exerts counter-pressure on the other side of the chest. Hunerfauth gives at first a ten minutes' treatment, and gradually leads up to two treatments of twenty minutes each. He had in this way several years previously "cured" four cases of severe "adhesive fibrinous pleurisy." The cure occupied six weeks, and was aided by gymnastics, douches, and cold water compresses. One wonders how the cure would have progressed with these latter means without massage ! I cannot prevent people believing in Hunerfauth's pleural massage, but no one can force me to place greater faith in it than in Oertel's heart massage.