Individuals who are weak and whose circulation is poor should not attempt the hardship of surf bathing.

Sulphur baths are advocated for various conditions such as rheumatism, and for some skin diseases, and they are especially advised to eliminate metallic salts from the body, typically mercury after it has been long administered for syphilis. These baths are best given at the sulphur springs. It has not been shown exactly what benefit occurs from a sulphur bath besides the psychic effect. Mud baths given at these springs are also considered of great value. Mud applications to a rheumatic, gouty, or otherwise diseased joint may be of benefit as a poultice proposition, and the effect is doubtless no different from that caused by a similar local application made at the patient's home, unless the mud is radio-active.

Oil of pine added to a bath makes the so-called pine needle bath. The effect is stimulating and irritating to the skin. The inhalation of the vapor of pine while the patient is in the bath may be of some advantage in throat and upper air passage inflammation, but this action can be more easily obtained by direct inhalation of mixtures containing pine oils.

The carbon dioxide bath has been much used in cardiovascular-renal disease and to reduce high blood-pressure. These baths were lauded at the Nauheim springs in Europe, and have acquired celebrity for that reason. The object is to furnish bubbles of carbon dioxide by mixtures of salts that will produce effervescence. These bubbles strike the skin and cause slight irritation and hence increase peripheral circulation, to the relief of internal congestions and a slight lowering of blood-pressure. A patient with low blood-pressure should not take this kind of a bath. These baths, whether given at the springs, in sanatoria, or at home, should ordinarily not be used in chronic nephritis. Salts for these baths can be obtained in packages ready for use.

The Nauheim baths are divided into three types: the natural carbonated salt bath; the bath in which either the carbonated water or the brine is artificial; and the bath in which both the brine and the carbonic acid are artificial. The natural bath is found at Nauheim. Natural brine baths have been thought by

some to have better action than artificial brine baths; consequently it is thought that the artificially carbonated bath with natural brine is a little better than when the water is carbonated and the brine is added, or when both the brine and the carbonic acid are artificial.

Various forms of douches, both hot and cold water, are used, best directed from a douche table, which can govern not only the direction of the douche, but also the temperature of the water and the force with which it is projected. These douches are termed the sheet, the circular, the revolving jet douche, and the needle spray. The effect of some of these douches may be profound, and care should be taken lest shock is caused. Steam douches are sometimes given. A hot douche followed by a cold douche is termed the Scotch douche. The head should not be treated by douches, although a simple shower may be directed over the head.

MASSAGE

This is one of the most useful of the so-called physical therapies. It can be given gently enough to quite pain, or strenuously enough to break up adhesions. It can be given to promote the nutrition of the skin and the flow of blood in the surface veins, or to increase the flow of blood and lymph in the muscles, and thus promote muscle nutrition. It can be given to quiet a patient to sleep, or to stimulate him to increased exertion. It can be used in the seriously sick to gently promote the sluggish circulation in the muscles and skin and thus to aid in the elimination of toxins, or it can be used to remove the fatigue of the athlete to prepare him for renewed effort.

The operative technique of massage cannot be taught by book, it must be learned by personal operation under the instruction of an expert and by long practice on the human body, and even then a good masseur, or masseuse, is, like the poet, born and not made. A physician rarely has the time or the training to do good massage, but he should sufficiently understand the subject to decide that massage is advisable; the kind of massage needed; the length of time it should be given; and the improvement to be expected. He must also recognize when

massage is contraindicated and when it is doing harm. After selecting the operator for a patient, generally best one of the same sex, the physician should order what he wishes done, as he would give any other order for the management and care of his patient.

The nervous effect of the massage on the individual has largely to do with the personality of the operator. The intimate relations into which these two people must come, the operator and the patient, necessitates that the operator be forceful, cheerful and have a pleasing personality. There is no question that too vigorous, or ill advised, massage on sensitive parts of the body may render a patient very nervous and irritable. On the other hand, there is no question that general massage is sometimes very quieting and soothing, and a calm, gentle operator may almost cause a hypnotic quieting influence. There is without doubt some electrical exchange between the operator and the patient. Hence in nervous individuals, or where massage is used to quiet and to produce restfulness and sleep, the operator must not only be an expert, but well chosen. For massage that is not general, but for some local disturbance, such a careful choice is not needed.

Generally no lubricant should be used; at least a competent operator does not need a lubricant. He knows what parts of the body to operate gently; he is careful not to rub on tender spots too severely; and is careful not to irritate and bruise the skin. In massaging very hairy persons a little talcum powder, or some oily powder, may be used, or a wool fat made less tenacious and more emollient by oil of sweet almonds may be used. Cocoa butter is a lubricant frequently used. Vaseline or any other petroleum oil should not be used, as it is likely to irritate sensitive skins and promotes the growth of hair more than other fats.

If there is an eruption on the patient's skin, some thin, clinging garment should cover him and the massage be done through it. It is, also not necessary for the skin to be absolutely uncovered if the object is to massage some deep-seated muscle or nerve.

General massage should ordinarily last about an hour, each

extremity being operated upon about ten minutes, the rest of the time being spent on the body. With very large or very fat people the massage may be given for a longer time than an hour. At first, general massage should be given daily; later less frequently. If pain is caused the massage should be stopped; or if the patient feels exhausted after the massage, subsequent treatments should be shorter. The best time for massage is some hours after a meal, and if it is found to be quieting to the patient, it may be given just before bedtime. The patient must always be at rest, and the operator must be at ease. Needless to state, it is well for the patient to have previously had a bath; and the operator should have clean hands, short nails, and wear no rings. With these simple precautions, infection will not be rubbed into a tender skin.

It is best for the patient to lie on a stiff bed or couch, between blankets, and otherwise without covering, unless a thin covering is advisable. For general massage usually manipulations are begun on the lower extremities, then the arms, then the back, then the chest, and last the abdomen.

There are technical names applied to the various kinds of massage. Those that are most important are: effleurage, which is stroking; friction, which is rubbing; tapotement, which is beating or tapping; pétrissage, which is kneading. Rapid tapping is termed vibration; pullings, stretchings, and bendings are part of practical massage.

The most gentle of these applications is effleurage, which consists of gentle rubbing and stroking, generally from the periphery toward the center, to promote the surface venous circulation. If this stroking is rather forceful, it also aids the flow of the lymph in the lymph vessels. This rubbing and stroking should generally be slow, and in tender parts, very gentle. Friction is simply more active rubbing, and the strokes may be upward, or in circles about a sore spot or joint and where there is extravasation or exudate, which it is the aim to remove. This kind of rubbing may be used on painful nerve regions to change the circulation in the deeper parts, provided there is no inflammation.

Tapotement is when the muscles are tapped with the fingers

or with the hand or gently slapped with the flat of the hand. Gentle, rapid percussions represent the vibratory treatment.

By pétrissage is meant the grasping of a muscle or group of muscles and kneading, squeezing, and lifting them; or the muscles may be rolled with the fingers or hands. The effect of this type of massage is to improve the circulation of the blood and lymph in a muscle. Muscle cramps and myalgia are thus treated, and fatigue products are thus removed from the muscles.

The first effects of proper massage should be an increased activity of each manipulated muscle as shown by its becoming larger and firmer, due to the increase of its blood supply. The after effect of a general massage should be, for some time at least, an increased tone. If general massage is doing good, this tonicity should last longer and longer after each treatment. The color of the skin should improve on account of its increased circulation, and it should become more moist; a rigid, hard, rough skin should become softer and more elastic. If this general massage is of benefit, the feeling of fatigue should be diminished, the patient should be less nervous, and general aches and pains should, at least temporarily, be abolished. Not only hysterical, but neurasthenic and convalescent patients are likely to have sore spots or tender spots on various parts of the body. Whether these are due to a disturbed circulation or to an imperfect absorption and elimination of metabolic salts, or to some other unexplained cause, they should all be improved by properly conducted massage. If the general circulation improves, the patient should sleep better, and his appetite and his digestion should be better.

Ordinarily general massage should represent all the different forms, beginning with gentle stroking, to be followed later with the more or less vigorous movements. The temperature of the body may rise slightly, especially if it has been subnormal. A paralyzed extremity in which the temperature has been subnormal may have its temperature raised several degrees, due to the improvement in circulation. As more blood flows to the surface of the body, unless the patient is very nervous or is irritated by the massage, the pulse becomes slower. Occa