ercise (D) consists in from the sides (Fig 1) al (Fig. 3) and then Fig. 6), taking a deep g this act; then bendTig. 7) as far as possig in that position four taining the air (countby moving the hands ward and backward the fifth second exhalhile resuming the origigs. 3 and 1). During en the arms are raised join, do not bring the e head, but form a sort the head by bending ard far enough so that the index fingers and triangle (Fig. 6).

cise (E) is for the purthe abdominal muscles or in other words, for minal and chest breathd assume an erect posibeginning of all the exhands meet in front ingers and the edge of ing the abdominal musWhile taking a deep inthe diaphragm, concenion on this act, and move the joined hands them along the thorax he chin. Next turn the and continue to raise y are above the head backward (Fig. 7) duronds while retaining the hale, lowering the arms he horizontal (Fig. 3) he original position of 'ig. 1).

reathing or respiratory hich may also be called uires more strength and

a few weeks, and until an evident improvement in breathing and general well-being has been observed. Take the usual position of military "attention" and then stretch the arms out as in the act of swimming (Fig. 11), the backs of the hands touching each other. During the inspiration move the arms outward (Fig. 12) until they finally mees behind the back (Fig. 13). Remain in this position for the usual four seconds, counting by moving the hands while retaining the air, and on the fifth exhale, bringing the arms forward again (Fig. 14), ready to start for another swim (Fig. 11); or if this is the end of the dry swim, the arms return to the original position of “attention" (Fig. 1).

This somewhat difficult exercise can be facilitated and made more effective by rising on the toes during the act of inhalation (Fig. 12) and descending during the act of exhalation.

It will be seen that with the aid of these six respiratory exercises every muscle of the body is put into play. The face alone is at rest, and can serve as an indicator that the exercises are properly done, for it should be borne in mind that they must be taken without any undue tension of the muscular system, and tremorlike movements must be avoided.

The following general rule concerning breathing exercises should always be remembered: Commence with the easier exercises (A) and do not go on with the more difficult ones until the former are completely mastered, then take from four to six respiratory exercises at a time, one of each, or when out of doors simply the first exercise, from four to six times every half hour or hour, or at least four to six times a day and on rising in the morning and on retiring at night. Continue this

practice until deep breathing has become a natural habit. These exercises should always be taken in an atmosphere as fresh and as free from dust as possible. Never take these breathing exercises when tired, and never continue so long as to become overtired. I repeat once more the important injunction that the muscles of arm and forearm, or any of the other muscles coming into play during the respiratory exercises, should never be on a tension but rather relaxed, so as to avoid the expenditure of unnecessary muscular energy.

Besides the exercises described above, there is one more that the recovered tuberculous soldier or sailor can add as

a

means to develop his chest and whereby he can take in the greatest possible amount of pure, fresh air. To this end he should proceed as follows: Take the usual position of "attention” (Fig. 1), then inhale deeply, rolling the shoulders upward and backward, holding the air for four seconds (Fig. 2), and on the fifth second exhale all the air possible. Assume again the original position (Fig. 1); but before inhaling again, make a second expiratory effort while turning the arms outward (movement of supination) and pressing the inner side of the upper arm against the chest (Fig. 15), and thus, so to speak, squeezing out all the air there is left in the lungs. An emptiness in the lungs is created in this way and the patient involuntarily takes a very deep inhalation (Fig. 16), after that assuming the ordinary quiet position of “attention." (Fig. 1).

With the aid of all these exercises we bring about an increase in hematosis. From our physiologic studies we recall that during ordinary inhalation and exhalation the amount of tidal air inhaled is only 500 c.c. The volume that can be inhaled by the first exercise is 1,500 c.c., known as complemental air, and the volume that can be

exhaled by this exercise-supplemental air-is about 1,300 c.c. When now the second expiratory effort is added, aided by the supination of the arms and pressure against the chest, 500 c.c. more of reserve or residual air can be expelled. It is evident that this last exercise tends to enhance the value of respiratory-therapy.

Before closing the chapter on respiratory exercises, I must state that my recommendation for this type of physiotherapy has been criticized a number of times because it was thought by some that the respiratory exercises would stimulate the tuburculous process to greater activity. Another criticism was to the effect that a mistake might be made by the less experienced clinician in declaring a case arrested when in reality it was still active. To these criticisms I would wish to reply by stating that I believe my auditors and readers did not realize that I was not prescribing respiratory exercises for the tuberculous patient but for the cured individual whose tuberculous process had been arrested. But I confess my shortcomings, I had failed to point out in my lecture the inestimable advantage to be gained by letting the patient gradually take breathing exercises before allowing him to resume physical labor of any kind. Relapses occur frequently in cases where the physical examination does not reveal any activity and there are no symptoms. The patient is pronounced an arrested case and allowed to leave the sanatorium. Yet he relapses after a few days or a few weeks of physical labor. I believe we have all made mistakes in allowing patients to go to work too soon, at least I am sure I have. But now, instead of telling the patient to go to work as soon as all the active symptoms have quieted down and only the physical signs of an arrested case remain, I start graded breathing exercises and the patient is

esh and as free from dust Tever take these breathwhen tired, and never ng as to become overt once more the importhat the muscles of arm r any of the other musto play during the resses, should never be on rather relaxed, so as to enditure of unnecessary gy.

exercises described above, more that the recovered

dier or sailor can add as develop his chest and an take in the greatest at of pure, fresh air. To ould proceed as follows: - position of "attention" inhale deeply, rolling the ard and backward, hold

four seconds (Fig. 2), Eth second exhale all the Assume again the original 1); but before inhaling second expiratory effort the arms outward (movemation) and pressing the he upper arm against the ), and thus, so to speak, all the air there is left An emptiness in the ed in this way and the ntarily takes a very deep g. 16), after that assumtry quiet position of "atig. 1).

id of all these exercises at an increase in hemator physiologic studies we iring ordinary inhalation a the amount of tidal air ly 500 c.c. The volume nhaled by the first exerc.c., known as compled the volume that can be

by the supination of the arms and pressure against the chest, 500 c.c. more of reserve or residual air can be expelled. It is evident that this last exercise tends to enhance the value of respiratory-therapy.

Before closing the chapter on respiratory exercises, I must state that my recommendation for this type of physiotherapy has been criticized a number of times because it was thought by some that the respiratory exercises would stimulate the tuburculous process to greater activity. Another criticism was to the effect that a mistake might be made by the less experienced clinician in declaring a case arrested when in reality it was still active. To these criticisms I would wish to reply by stating that I believe my auditors and readers did not realize that I was not prescribing respiratory exercises for the tuberculous patient but for the cured individual whose tuberculous process had been arrested. But I confess my shortcomings, I had failed to point out in my lecture the inestimable advantage to be gained by letting the patient gradually take breathing exercises before allowing him to resume physical labor of any kind. Relapses occur frequently in cases where the physical examination does not reveal any activity and there are no symptoms. The patient is pronounced an arrested case and allowed to leave the sanatorium. Yet he relapses after a few days or a few weeks of physical labor. I believe we have all made mistakes in allowing patients to go to work too soon, at least I am sure I have. But now, instead of telling the patient to go to work as soon as all the active symptoms have quieted down and only the physical signs of an arrested case remain, I start graded breathing exercises and the patient is