The Art of Massage
J. H. Kellogg, M.D.
    The importance of rest as a therapeutic means in the treatment of certain forms of disease and morbid conditions, especially in surgical cases, has long been recognized by scientific physicians; but it is only within recent times that this most important of nature's various recuperative agents has been systematically studied, and a method of treatment organized to which the term "rest-cure" could be appropriately applied. Mitchell was not the first, however, to present the subject in a methodical form. John Hilton, president of the Royal College of Surgeons, of England, had, long before, dwelt with much emphasis upon the importance of rest in the treatment of disease, and devoted a volume of considerable size to its proper employment in painful maladies. It must be granted, however, that Dr. Mitchell was the first to conceive a systematic treatment by rest combined with massage and a regulated regimen, a fact which has received world-wide recognition by the medical profession.
    As a therapeutic agent, rest belongs in the category of natural agents, with exercise, diet, baths, etc. It is perhaps for this reason that it was so long neglected, as were also dietetics and hydrotherapy, which have only recently begun to receive the attention that their importance demands. Sleep, nature's great restorative, is the most powerful of all recuperative measures, for the reason that during sound sleep the nearest possible approach to perfect physiological and mechanical rest is secured. Rest, even during sleep, is not absolute; otherwise the life processes would cease, and death ensue. The advantages of the rest afforded by sleep are illustrated by many facts.
    Both plants and animals require physiological rest. During its waking hours, which usually correspond to those of daylight, the animal expends energy in muscular and nervous activity. It gathers its food at the cost of more or less exertion, and otherwise exercises its powers in providing for its individual comfort or that of others. During sleep these expenditures cease, and the energies of the body may be solely employed in the repair of the injuries and losses which have occurred during the hours of waking activity. It is during sleep, when the force of the vital powers is thus concentrated upon the organism itself, that both animals and plants make the principal part of their growth.
    Physiological and mechanical rest has long been known to be the best means of promoting recovery in cases of injury, and it is equally valuable in recruiting depleted vital energies or in repairing a breach in the continuity of the tissues. In cold climates, trees and plants take physiological rest during the winter months; while in warm countries a similar rest is afforded by the dry season. The water-lily of Egypt flourishes in the canals during the wet season, when they are filled with water for irrigating purposes, but disappears utterly during the dry season, when the canals are empty, and their beds so dry and hard as to be used for roadways. When the floods come down the Nile, and the water flows into the canals, the lily, recuperated by its rest, blooms again. During the brief summer season of the Arctic regions, flowers and plants spring up after their long sleep, and attain maturity in a shorter period than in any other part of the world.
    Another evidence of the universal necessity for rest is afforded by the fact that plants while in bloom, in many instances exhibit evidences of sleep very similar to those shown by animals, closing their leaves or their flowers when the sun approaches the western horizon.
    Growth and exercise are in opposing relation to each other. It is true that exercise promotes growth, but the growth does not occur simultaneously with the exercise. On the contrary, during periods of vigorous exercise, growth is checked. Increased oxygenation and improved elimination resulting from exercise are means of systematic invigoration which promote growth, provided the exercise be not carried to an extreme. By too great exhaustion of the bodily forces, growth is lessened.
    In the child, growth may be said to be chiefly confined to periods of rest and sleep. The full development of the body having been obtained, repair takes the place of growth. Incessant activity, which must necessarily be accompanied by the loss of sleep, produces a rapid waste of tissue, as well as anaemia from a diminution both in the number of corpuscles and in the haemoglobin, or coloring matter, of the blood. Sleep promotes tissue production and repair.
    Rest is necessary for the viscera as well as for the brain, the nerves, and the muscles. A viscus, as the liver or spleen, when at work, increases in size, from the unusual amount of blood circulating through its vessels. The diameter of the liver increases during digestion from half an inch to an inch. It is for this reason that the spongy viscera of the abdomen are each surrounded by an elastic capsule, which contains both muscular and yellow elastic fibers. The pressure of this elastic covering, constantly acting upon the organ, promotes its return to a state of physiological rest as soon as the demand for its activity has ceased.
    Even the brain enlarges during activity. The thick skull does not permit an actual increase in the volume of the brain as a whole, but nature has provided an arrangement by which an enlargement of the active parts may occur. The large lateral ventricles which occupy the interior of the brain on each side are constantly filled with cerebro-spinal fluid. The optic thalami and the corpora striata, the most active portions of the brain, are so placed that they project into the ventricles. When distended with blood, and thus enlarged, as they are during activity, these bodies project farther into the ventricles, displacing a quantity of the cerebro-spinal fluid, which passes through the foramen of Monroe, the third ventricle, the aqueduct of Silvius, the fourth ventricle, the cerebro-spinal opening in the floor of the fourth ventricle, and the sub-cerebral spaces, into the vertebral canal. When the activity ceases, the pressure of the cerebro-spinal fluid causes it to return to the lateral ventricles, thus keeping them. constantly filled, and providing suitable support for the blood vessels of the adjacent nerve structures. It has been shown that when the cerebro-spinal fluid is not present in the lateral ventricles, the brain cannot be injected without rupture of these vessels'
    The rhythmical activity of the chest is another means of securing the return of the brain and the viscera to a state of rest after activity. The diminution in pressure which occurs during inspiration ,makes a strong draught upon the blood current in the direction of the heart, thus aiding especially the venous circulation of the brain and also that of the liver, as well as that of the other abdominal viscera.
    Indications for Application of the "Rest-Cure." -More than twenty years' experience in the employment of the "rest-cure " in various forms has to the author amply demonstrated its value. It has been found especially successful in the treatment of the following conditions:
    Chronic Pain. - The rational treatment of painful maladies necessarily includes riot only the recognition and treatment of the cause of the malady, but also mitigation of, the pain itself, in consequence of the 'exhausting influence of long-continued pain, and the interference of this symptom with the normal processes of recuperation and repair. Rest and position are, in suitable cases, more effective in securing relief from pain than any of the ordinary sedative drugs, without rest. This is true of both local and general pains. The terrible pain of a felon may not infrequently be relieved to an astonishing degree by simply elevating the hand above the head. The pain of a rheumatic ankle sometimes disappears almost instantly, upon the sufferer's assuming a horizontal position, with the foot elevated. The pain of an inflamed nerve, as in sciatica, yields to prolonged rest more certainly than to any other treatment. The neurotic young woman who in an erect position suffers such intolerable spinal pain as to make existence almost unendurable, finds herself perfectly comfortable when in bed. Pelvic and abdominal pains often disappear as if by magic when the patient assumes a horizontal position. The relief thus afforded is often brought about by the removal of the tension upon the abdominal sympathetic nerve and its branches, which is secured by a reclining position.
    In a majority of cases of this kind, some of the abdominal or pelvic viscera will be found displaced, or in a condition termed by Glenard "enteroptosis." When the patient is in an erect position, the stomach, liver, kidney, bowels, - one or all - of these organs, - being in a pendant or floating condition, drag upon the sympathetic in a way which may set up pain and morbid symptoms of the most varied character, and in structures either near or remote. Pain attributable to irritation of the abdominal sympathetic from the cause mentioned, may be locally expressed in any part of the body from the heel to the top of the head. Rest in bed is a sovereign remedy for cases of this kind.
    Emaciation. - Progressive wasting of the tissues as indicated by a steady loss of flesh, is a morbid condition which sometimes proves most refractory to therapeutic efforts, especially when the means employed are exclusively of a medicinal character. There is, in fact, no drug which can be relied upon to secure a substantial and permanent increase in flesh. Emaciation is an evidence of a serious disturbance of nutrition; and when considerable in degree, or rapidly progressive, invariably demands a prompt and systematic application of the "rest-cure." An improvement in weight can be expected only as the result of an increase of residual tissue, or fat. This requires, first of all, an improvement in digestive activity, which may involve an increase in either the quantity or the quality of the digestive work done. Not infrequently, patients complain that, although they have a good appetite, and eat large quantities of food, they nevertheless steadily lose in flesh. In these cases, a thoroughgoing examination of the stomach fluid obtained after a test meal, shows the coefficient of digestive activity to be low,- in other words, the quality of the digestive products is so poor that they are, in large part, useless for the purposes of nutrition.
    Successful treatment of these cases requires, next after an improvement in digestion by which a larger amount of tissue-building material can be taken in, a careful economizing of the vital resources. As far as possible, the activity of, the bodily powers must be concentrated upon the building up of the individual. All external expenditures of energy must be cut off.
    Food is consumed in the body in three ways only -for heat production, force production, and tissue building. The food elements consumed in beat and force production cannot be deposited as tissue, or, at least, cannot be retained ; consequently the amount of nutritive material used in this way should be limited to the smallest amount possible. In no way can the vital resources be thus economized so effectively as by the aid of the "rest-cure."
    Fever. - In all cases in which there is any considerable rise of temperature or febrile activity, from whatever cause, rest is one of the most essential features of treatment. If the temperature rises daily, three or four degrees above normal, the patient should be kept in bed. If the elevation of temperature is not more than one or two degrees, the patient may spend a part of the time only, in bed; the balance of the time he may be dressed, if he desires, but should recline upon a cot, rolling-chair, or hammock. In this way the great waste of tissue which always accompanies fever may be very materially lessened, and the intensity of the febrile action greatly diminished. Rest in bed is one of the most valuable of all the means which can be utilized in the treatment of pulmonary tuberculosis, or consumption, during febrile paroxysms.
    The necessity of rest is well recognized in the treatment of typhoid fever and other acute febrile maladies, but its importance in the treatment of pulmonary consumption is often over-looked In the last-named disease the patient should be put to bed whenever the temperature rises above 101o.
    Neurasthenia. - This condition, commonly called nervous exhaustion, is one in which the "rest-cure" has achieved some of its most important and remarkable triumphs. The value of the "rest-cure" in the treatment of neurasthenia has come to be so thoroughly recognized that it is by some considered almost a panacea. This view is an extreme one; nevertheless, mechanical and, as far as possible, physiological rest of the brain and nerves is, for many cases of this kind, most important as a requisite for recovery. This is especially true of those cases of nervous exhaustion sometimes encountered in young men and women who have led aimless and idle lives, and whose morbid condition is the result of a mental and physical stagnation rather than excessive work. In the case of overworked and worried persons, especially those in whom the decline of health has been accompanied by a loss in flesh, the "rest-cure" is indicated as a therapeutic measure of the first importance.
    The Opium, Cocaine, Whisky, and Tobacco Habits . - In the treatment of these poison habits I have found rest a most valuable accessory means. The man or woman who has long been addicted to such a habit will invariably be found in a state of nerve exhaustion, and it is this condition of the nervous system, and the veritable cyclone of nerve symptoms which arises from it as soon as the toxic agent is withdrawn, so that the patient becomes conscious of his real condition, which renders the management of these cases so difficult. A person habituated to the use of any poison cannot be considered cured until the nervous system has been restored to a normal and well-balanced state. If the drug is simply withdrawn, and the patient left with a nervous system shattered by its pernicious influence, he will, in a majority of cases, find himself utterly unable to resist the importunities of his worn-out and pain-racked nerves for their accustomed solace. The morbid condition which constitutes an ever-present incitement to the perpetuation of the habit must be removed before the patient can be regarded as cured. "Rest-cure" is as valuable in the treatment of this form of nervous exhaustion as any other.
    Another very important reason for the employment of the "rest-cure" in these cases is the absolute control of the patient which it secures. The patient who has been long accustomed to the use of opium or cocaine, and even in some instances alcohol or tobacco habitués, require every possible assistance in getting through the first few days after the complete withdrawal of the accustomed drug, whether it is gradually taken away or suspended at once. In order to receive all the assistance possible from a rational system of treatment and by the aid of a trained nurse, the patient must remain in bed; for during this period he will require an application of some sort not only every hour but almost every moment, to quiet his clamoring nerves, as well as to while away the weary hours and beguile his mind into a normal channel. I have found the " rest-cure " of great value in the treatment of a large number of cases of the opium habit and other forms of drug addiction.
    Gastric Ulcer. - In this disease, there is not only marked wasting of the body in a majority of cases, in consequence of the disturbance of nutrition occasioned both by the ulcer itself and by the morbid condition of the stomach which precedes it, but there is also a local destruction of tissue, which is aggravated by exercise. The irritability of the stomach and the highly excited state of the solar plexus render exercise upon the feet, in many of these cases, extremely painful, such exercise often giving rise to most distressing paroxysms of pain and gastric crises. By rest in bed, the patient's forces are economized; nutrition is improved ; and more favorable conditions for recovery are secured.
    Gastric ulcer is usually a consequence of long-continued hyperpepsia. Exercise upon the feet has a marked tendency to increase the hyperpepsia, and thus promote the development of the ulceration; while mechanical rest has an opposite effect. In most of these cases it is also necessary to give the stomach complete physiological rest by withholding altogether the administration of food by the mouth, and administering only specially prepared foods by means of the rectum. While the nutrition is thus restricted, absolute rest in bed is most important as a means of preserving the forces of the patient.
    Hemorrhage. - After severe hemorrhage from any cause, as from the lungs in pulmonary disease; from the uterus in cases of fibroid tumor or other diseases of that organ ; from the rectum, in consequence of ulceration or bleeding hemorrhoids; or from any other cause whatever, a more or less prolonged rest in bed is of the utmost importance as a therapeutic measure, and is in the highest degree conducive to the replenishment of the blood. In a number of cases of this kind the writer has noticed, during rest, an astonishingly rapid restoration of the hemoglobin and a return of the normal blood count.
    Diseases Peculiar to Women. - While many diseases peculiar to women are the result of neglect to properly develop the muscles, especially those of the trunk, nevertheless, in a large number of the morbid conditions from which they suffer, a short course of "rest-cure " may be employed with very great advantage. This is especially true in all inflammatory diseases of the ovaries and uterus. Severe cases of uterine and vaginal catarrh are also greatly benefited by rest in a recumbent position. The effect of position upon the circulation of dependent parts is readily shown by noticing the change which occurs in the circulation of the hand when lifted above the head from the usual position by the side. If the veins are much swollen, as is likely to be the case when the arm swings by the side, it will be observed that instantly, when the hand is raised above the head, or even to the horizontal position, the fullness disappears, and the skin of the hand becomes blanched. This is not simply the result of gravity acting upon the blood, but is due chiefly to a decided contraction of the blood vessels in the hand. A like change occurs in the pelvic viscera. The swollen state of the blood vessels induced by the vertical position must greatly aggravate any pathological condition of the uterus or its appendages when congestion, either active or passive, is a prominent feature of the morbid state. The writer has frequently been told by patients that vaginal or uterine catarrh was always greatly increased during or after exercise upon the feet, and has seen such discharges disappear entirely during prolonged rest in bed, evidently as the result of the diminished circulation secured by the recumbent position.
    Prostatic and Bladder Disease. - The remarks which have been made with reference to diseases peculiar to women are equally true with reference to acute disease of the bladder, urethra, prostate gland, or the genital glands, in men. An acute cystitis, urethritis, or prostatitis will be more readily benefited by rest in bed than by the employment of any other means. The same must also be said of orchitis, a disease which not infrequently resists treatment with great obstinacy, without the advantage of the recumbent position. In many cases of chronic disease of the bladder in both men and women, "rest-cure" is of paramount importance as a therapeutic measure.
    Bright's Disease of the Kidneys. - The various pathological conditions of the kidney included under the term "Bright's disease " not infrequently demand rest in bed as a necessary condition for a cure of the disease, or even an arrest of its progress. This is especially true of acute inflammation of the kidneys. In this disease there is a lessened ability of the kidney to eliminate poisons; consequently, the disintegration of tissue which occurs as the result of exercise upon the feet necessitates increased eliminative work on the part of the kidney. Exercise on the feet, and even sitting or standing, also involves greater activity of the heart and a higher arterial tension. An abnormal increase in arterial tension may be, in itself, sufficient to cause the appearance of albumen in the urine. It is evident, then, that in cases of acute inflammation of the kidneys, whatever tends to increase the arterial tension must aggravate the disease; and, on the other hand, the lessened arterial tension induced by rest in a horizontal position must favor recovery. In a somewhat extended experience in the treatment of this disease, the author has found rest an exceedingly valuable accessory.
    Disease of the Heart. - In the history of a case of organic disease of the heart, the first morbid condition of grave character which requires the attention of the physician, is often over-compensation. The unusual amount of work required of the organ induces an excessive development of the heart muscle, and this excessive cardiac activity results in a variety of disturbing and often alarming symptoms. There is no way by which the heart's action can be so quickly and so safely quieted as by means of rest in the recumbent position. There is no drug which is, even in a small degree, a substitute for rest, in cases of this kind.
    In cases of cardiac insufficiency, rest in bed is equally as valuable as in cardiac hypertropby with overaction of the heart. When the heart has become so weak as to be unable to maintain the circulation, the relief from work afforded by rest in the horizontal position enables the heart to recover itself, so that, after a few days or weeks, as the case may require, the normal balance of the circulation is re-established; the heart, no longer distended and embarrassed with blood from which it has lost the power to empty itself, recovers its tone; the pulse becomes fuller and stronger; the cyanosis disappears; the swollen limbs return to their normal size; and the respiration is no longer embarrassed.
    Nervous or Mental Irritability or Excitability. - For certain cases of extreme nervous or mental excitability bordering on acute mania, and especially in cases of acute maniacal excitement, rest in bed, accompanied by appropriate treatment, is a measure of such great advantage that I should feel very loth indeed to undertake the treatment of cases of this sort without its aid. Rest in the horizontal position not only lessens the waste of tissue resulting from abnormal nervous or mental excitement, but secures to the patient the isolation and quiet which may exercise in a high degree a calming influence upon, 'his overexcited nerves.
    The Significance of Pain. - In the selection of cases to which the "rest-cure" should be applied, it is necessary to understand clearly the significance of pain. Not infrequently the pain experienced is very remote from the part which is the real origin of the pain, and to which, accordingly the therapeutic measures should be directed.
    In the employment of the "rest-cure" as a means of relieving pain, it is. very important to distinguish between pains which are purely local in character, and those which are of reflex origin. Local pains, or those originating in the parts where they are felt, if involving but a small portion of the body, may require rest only of the part itself. But sympathetic, or reflex, pains generally require complete rest. This is true, for example, of the intercostal pains connected with pleurisy, either acute or chronic, or adhesions of the pleura resulting from inflammation. The pleura and the overlying tissues are supplied with branches from the same sensory nerves. This fact should always be kept in mind, and should lead to a careful examination of the lungs in cases in which thoracic pains are experienced.
    Quite a large proportion of all external pains are connected with disease of the viscera. Pain between the shoulders or above the lower angles of the scapulae, a, very common chronic pain, indicates some disturbance of the fourth, fifth, and sixth spinal nerves. The nerve centers from which these nerves ,originate are those which chiefly give rise to the great splanchnic, or visceral, nerve, which is distributed to the stomach, liver, pancreas, and intestines. Its branches are also closely interwoven with the solar plexus and the lumbar ganglia of the sympathetic. It is consequently clear that the pain described may readily be produced by disease of the stomach, intestines, pancreas, liver, or some other viscus; and a careful investigation will usually show a prolapsed stomach or liver, a floating kidney, sagging of the bowels, or several of these conditions associated, whereby an abnormal and nerve-irritating condition is induced, affecting the branches of both the sympathetic and the splanchnics.
    One-sided pain, is, as a rule, an indication of a one-sided disease, while bilateral pain indicates a morbid condition affecting both sides. Even in cases arising from disturbance of the viscera, this rule holds good more frequently than might be expected. Migraine affecting one side of the head is, in the experience of the author, frequently connected with extreme hyperaesthesia of the lumbar ganglion of the same side. If both ganglia are affected, the patient will say that the attacks occur simultaneously upon both sides, or extend from one side to the other. In these cases, the greatest tenderness will usually be found in the lumbar ganglion of the side upon which the pain first begins. In cases in which the attack begins in the back of the head, extending thence upward over the whole head, both ganglia are usually found equally affected. In cases of pain arising from visceral disease, rest in bed for a week or two at the beginning of the treatment is a measure of very great advantage. At the conclusion of the period of confinement in bed, care should be taken to keep the organs in position by a properly adjusted supporter and appropriate applications of abdominal massage.
    Disadvantages of the "Rest-cure." - It should never be forgotten that rest in bed involves certain disadvantages, against which careful provision must be made. Man is naturally an active animal; and habits of. regular, systematic exercise are essential to the maintenance of the integrity of, the vital functions. Absolute rest in bed, without the employment of proper preventive measures, is, in itself, sufficient in many cases to provoke grave morbid conditions. The muscles, of course, rapidly deteriorate under the influence of inaction, but this is a matter of small importance compared with the injury sustained by the liver and other viscera. It is a common observation in surgical wards and hospitals that a healthy man confined in bed from fracture of a limb, becomes bilious, some-times even jaundiced, in consequence of interference with the functions of the stomach, liver, and bowels. The unpleasant effects of rest are readily understood when the important influence of exercise upon the viscera is recognized.
    Exercise necessarily involves increased chest activity. The lungs constitute not only an air pump by which oxygen is .supplied to the body, but, at the same time, exercise a most important influence in assisting the circulation and thus the functional activity of the stomach and liver.
    The diaphragm not only acts as a great lymph pump, but by compression of the stomach and liver during the act of forcible inspiration, it exercises these important organs, and by promoting absorption, aids in emptying the stomach of its contents while, by mechanical compression, it empties the liver of bile, and hastens the passage of the blood through its capillaries.
    Perhaps more important still is the effect of exercise upon the general system in promoting the complete oxidation, or burning up, of the waste matters which are continually accumulating in the tissues through increased absorption of oxygen, and by draining off the poisonous waste substances prepared for removal from the body, and hastening their transportation to the liver, kidneys, lungs, bowels, and skin, through which they make their exit from the body. Diminished respiratory activity alone may be responsible for a congestion of the stomach and liver resulting in stomach and intestinal catarrh, infectious jaundice, and inactivity of the liver and bowels.
    The horizontal position may also result in injury on account of the congestion due to the mechanical accumulation of blood in the dependent parts. Pneumonia not infrequently results from lying continuously upon the back during a course of typhoid fever or some other disabling malady. Even cerebral congestion may result from the horizontal position.
    These and other disorders, the nature of which may be inferred from what has been said in reference to the influence of rest in producing these morbid conditions, may be prevented by the adoption of proper measures, the most important of which are massage and manual Swedish movements. The utility of massage in these cases need not be argued, as it is apparent at once that it may be made, to a very large extent, a substitute for exercise, without expending the nervous energy of the. patient, or making any large draughts upon his vital resources.
    These facts give massage a value which cannot be overestimated. It is a means by which the patient may receive the benefit of exercise without effort on his part; and in most cases in which "rest-cure " is required, massage must also be employed as a complementary measure. A few exceptions only need be made. These are so important, however, that they must not be overlooked. First of all, it must be remembered that in febrile conditions, or at least in all cases in which any considerable degree of febrile activity exists, massage must not be applied, for the reason that it increases heat production. In most cases, bathing and rubbing must be employed, to a greater or less extent; but care should be taken to avoid all manipulative measures except stroking and centrifugal friction, the tendency of which, as regards heat production, is the opposite of all the other processes of massage. In the employment of the "rest-cure" for the relief of pain due to visceral prolapse or other diseases of those organs, manipulation of the diseased viscera must be avoided except so far as may be necessary for replacement; but massage to the limbs and other parts of the body may very wisely be employed, since, when administered in this manner, it operates most efficiently as a derivative measure.
    In acute Bright's disease of the kidneys, massage must be avoided, or at least should be confined to the gentlest measures, for the reason that the kidneys are crippled, and it is desirable that their work should be restricted as much as possible within safe limits. A vigorous application of massage may suddenly throw into the, circulation so large a quantity of toxic and excrementitious substances as to overwhelm the kidneys and create an increase of irritation, the result of which might be disastrous. Stroking (169-190) and centrifugal friction are the only appropriate measures for cases of this kind until after there has been a marked diminution in the activity of the disease, as shown by a decrease in the production of albumen and an increase of urea, or a marked rise in the coefficient of toxicity.
    In cases of excessive nervous and mental excitability, massage must be used only when great care is taken to select the right measures, and the treatment in such cases must be administered with unusual skill. The lighter measures of massage only are admissible in these cases. Percussion must generally be altogether interdicted. Gentle, deep kneading (246) and centrifugal friction (194) are most appropriate measures, and these should be employed derivatively.
    Among the most valuable preventive measures to be employed in massage when administered in ordinary cases of " rest-cure," should be mentioned abdominal massage (389-424). Massage of the stomach (451), bowels, and liver aids greatly in counteracting the evil effects of rest upon these viscera, and in facilitating the processes of digestion and elimination, in fact promoting all the functions of the organs named, as well as those of the kidneys.
    Another measure of greatest importance, in addition to general and abdominal massage, is to be found in lung gymnastics (381-384), which not only greatly aid the functions of the liver, stomach, and other viscera, but also relieve the brain of blood, thus preventing cerebral congestion, and promote elimination. Breathing exercises also promote the formation of blood, thus preventing anaemia, and greatly aiding the oxidation and elimination of waste matters. These exercises are valuable not only in ordinary cases, but in fevers, Bright's disease, and in fact in every case in which the "rest-cure" is employed, except acute pleurisy and pulmonary hemorrhage, in which, of course, it is important to secure as great a degree of quietude as possible.
    The employment of lung gymnastics in fevers is a valuable means of combating the depressing tendency of the disease, and of preventing the pneumonia which frequently accompanies fevers of a low type. It also aids in lowering temperature, not only by cooling the blood, but also by assisting in oxidation and elimination of the toxic substances to which the rise of temperature is due.
    Ewald measured the temperature of the stomach by a thermo-electric device, and found it to be, on an average,. lo F. higher than in the axilla. By making the patient breathe forcibly, even with the mouth closed, the temperature of the stomach was reduced to half a degree less than the axillary temperature. When the patient breathed steam at the temperature of the body, this lowering of the temperature of the stomach did not occur, showing that the internal temperature may be lowered by bringing the blood into contact with an increased quantity of cool air through forced respiration.
    This measure has not been employed in febrile cases as much as it deserves to be. It is, of course, important that the patient should be entirely passive. The increased breathing activity should be secured by movements executed by the masseur, who, by raising the arms from the sides and drawing them upward, will aid inspiration; then, by returning them to the sides, and compressing the sides of the chest, may aid expiration. Cyanosis, which so frequently accompanies febrile action when the temperature rises to a dangerous point, may be made quickly to disappear by this means.
    Position is a matter also worthy of mention as a means of combating some of the evil tendencies of rest. In cases with a tendency to cerebral hyperaemia, the head of the bed should be raised, thus utilizing gravity as a means of securing drainage of the brain. This is especially important in cases of apoplexy, and the same measure should be employed in pulmonary hemorrhage. In hemorrhage from other parts of the body, resulting in ansemia, the opposite plan should be followed, the foot of the bed being raised. This measure should also be adopted whenever it is desirable to antagonize congestion or inflammation in the lower extremities. Pelvic pain due to disease of the ovaries or of the bladder, prostate, or rectum, is often greatly relieved by raising the foot of the bed, in connection with rest in the recumbent position.
    From what has been said, it is evident that massage is practically indispensable as a complementary measure of treatment in connection with the " rest-cure," and that it may be applied in some form in all cases requiring rest, and in such a manner, as to greatly increase the advantages which may be derived from the "rest-cure."
    After-rest Exercise. - A point of very great importance, to which attention should be called, is that rest alone seldom results in a radical cure. Rest secures a symptomatic cure, but does scarcely more than this, except to provide conditions favorable for recovery. Other recuperative measures must also be employed in connection with rest. Massage has been shown to be an invaluable remedy for this purpose. The "rest-cure," is only a preparation for exercise-cure. The patient who has been put to bed, and who has been relieved of his morbid symptoms by the rest thus obtained, must be made capable of enjoying good health upon his feet. To be cured in bed is not sufficient, as few sick people desire to spend their lives there. The patient must be gotten upon his feet, and enabled to endure at least an ordinary amount of exercise without injury, before he can be considered well. Neglect of this point has resulted in a failure to effect anything more than temporary relief by means of the "rest-cure" in perhaps a, large proportion of all the cases in which this measure has been employed. But as this point has been considered quite fully elsewhere in this work, the reader is referred to what has already been said. The author would, however, emphasize the importance of supplementing, in every case, a course of "rest-cure" with a course of carefully graduated exercises, by which the patient may be safely introduced to life under ordinary conditions. The author expects to be able to place in press at an early date a work in which will be given many such series of exercises, adapted to different conditions.