In my chapter on walking (p. 156) 1 have already referred to it as the best form of gymnastic exercise in diseases of circulation, respiration, and metabolism. Systematic prescribed walking on level and on sloping ground, here described under the name of Stokes' Terrain-cure, is of much greater importance than any other gymnastic system because of its wide therapeutic use. Besides its smooth continuity, which exerts a constantly renewed effect, it has, as compared with exercise of any kind whatever performed in enclosed, often dark, stuffy gymnasia full of dust and bacteria, the advantages of fresh air, sunshine, and other vitalising influences. It is difficult for the gymnastic specialist, into whose sphere the terrain-cure has made a marked inroad, fully to appreciate it, and, prejudiced as he may be, he is supported by the common tendency of mankind to value the costly and the complicated rather than the simple and inexpensive. But the unprejudiced, broad-minded and clear-sighted physician will always prefer the Stokes' cure to gymnastics and gymnasia in all cases except those in which there is some definite reason for a different treatment. These cases consist largely of deformities, especially curvatures of the spine, the combined treatment of which by gymnastics, orthopaedics, and massage has already been discussed; also of those cases where the joints other than the lower extremities require exercise; of the numerous cases in which inability to walk, or other external circumstances, place the terrain-cure out of the question; and, lastly, of cases in which it is no longer possible to exercise the heart or influence it by active gymnastics, and for which the constant supervision of the physician is indispensable.

In this chapter I (The Meaning Of Massage And Its Technique) refer only to diseases of the heart and lungs. But I must remind my readers that the terrain-cure, the external conditions and simple technique of which are stated, plays an important part in the treatment of dystrophies, especially obesity, and that it affords the best possible form of gymnastics in the treatment of diseases in the joints of the lower extremities.

Walking, especially in mountainous tracts, has, as Bamberger remarks, been in use for long as a therapeutic measure, especially in diseases of the heart. It was, however, the well-known clinician Sir William Stokes who (about the middle of the nineteenth century) first called attention to the fact that rational gymnastics, and especially mountain-climbing, can produce hypertrophic changes in and strengthen the heart just as exercise strengthens skeletal muscle, and who at the same time indicated the other necessary parts of the now well-known terrain-cure for heart disease* Stokes, like Wunderlich, saw that a greater quantity of blood in the vessels entails greater work on the heart, and it was Stokes who first ordered restriction of fluid instead of the repeated venous bleedings previously recommended by Wunderlich in order to facilitate the functions of the heart and to diminish the abnormal amount of fluid in the blood vessels. Stokes also ordered a diet rich in protein in order to produce the desired hypertrophy of the heart. And, finally, it was again Stokes who formulated certain important contra-indications to the terrain-cure.

A terrain-cure can, and moreover ought, in many cases to be conducted on level ground. In other cases to obtain the best results an ascent of 20° is needed, preferably spread over a considerable length. An ascent varying from 5° to about 10° or 12° is, however, the most useful and satisfactory in all cases, especially when the incline is fairly long. In several instances of diseases of the respiratory organs it is a great advantage if these inclines go through pine woods. In many cases of heart disease preference must be given to low or slight elevation over the sea rather than to high altitudes, where the atmospheric pressure is much diminished.

* In Stokes' "Diseases of the Heart and of the Aorta" (Dublin, 1854) we read (p. 357), for example, the following concerning treatment of fatty degeneration of the heart: -

"The patient must adopt early hours and pursue a system of graduated muscular exercises, and it will often happen that after perseverance in this system the patient will be enabled to take an amount of exercise which at first was totally impossible owing to the difficulty of breathing which followed exertion. . . .

"The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, as Switzerland or the Highlands of Scotland and Ireland. . . .

"His (the patient's) use of fluid should be as sparing as possible."

Stokes, besides this, recommends a diet rich in protein, discourages all that has a lowering effect, and also points out the necessity of avoiding the terrain-cure for advanced cases of arterio-sclerosis, etc.

Professor Oertel, of Munich, who wrote in the seventies and eighties, added to this treatment nothing more than"heart massage," which is worthless because of its foundation on faulty physiological principles, and the equally worthless and absurd "saccadee" respiration during mountain-climbing, and his detailed treatise, which certainly has some value, does not add anything essential to what had already appeared in the pregnant utterances of the British author. With all due recognition of the great service rendered by Professor Oertel in spreading the knowledge of the terrain-cure, I maintain that his claim to associate his name with this cure is quite unjustifiable.

The technique of all terrain-cures is on the same basis and extremely simple. Especially with heart affections, it is well for the patient to understand the importance of those rules which are made in order to prevent him over-fatiguing himself. During my practice at Carlsbad (Bohmen), with its facilities for such cures, I have always found it necessary to enforce the three following rules on my patients: -