inflammation there, but it has not been proved that ice or cold applications are valuable in inhibiting pneumonia. The ice coil is often of more value and is better adapted for applying cold to a part than the ice bag or cap. Cold should not be applied to any one part too long, as it not only inhibits the nutrition of the part, but may even cause death of the tissues.

When a part is to be frozen for anesthesia, ethyl chloride spray is more efficient and better to use than ice. While the ethyl chloride spray is being used, gas, lamps, and matches must not be lighted.

Special Forms of Water Treatment. The various forms of special methods of using hot and cold water have special names, and these special treatments are many. There are the various kinds of baths, hot and cold packs, and wet sheets, some of which have been mentioned. There is the hammock bath, which is not dissimilar to the tub bath. The hot sitz bath is of great value in relieving congestion in the head and in bringing more blood to the surface of the body and thus relieving localized congestion in the abdomen and pelvis. The foot bath also is an efficient means of relieving cerebral congestion, and of dilating the pelvic vessels. Mustard or salt added to these baths, causing irritation of the skin, may be of more value at times than plain water. Both of these ingredients may cause inflammation of the skin, and if there is eczema or dermatitis they should not be used. Insomnia may be relieved by a hot foot bath taken before going to bed; cold feet are not conducive to sleep, and individuals with poor circulation should wear bed socks. A hot water bag at the feet is not advisable, at least if it is to be frequently repeated, as it tends to soften the tissues, cause perspiration of the feet, and increase the tendency to catch cold. Any dry warmth to the abdomen may aid in producing sleep.

Sea salt is often added to a general bath as it causes greater irritation of the skin and therefore a longer increased peripheral circulation than occurs from the plain bath. Sea bathing is more stimulant than fresh water bathing, and if exhaustion is not caused by bathing too long in the surf the general stimulation after coming from the ocean bath lasts for some time.

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