Massage is of value in some skin affections. There are, however, contra-indications. For deep effleurage in particular the skin must be in tolerably good condition, and this manipulation is impossible in the case of certain injuries and diseases of the skin, where it might be easily broken. In the milder lesions, when massage may be given, one must remember that it increases the danger of infection of various kinds, and it is well, therefore, as a prophylactic to use an antiseptic. In the case of toxic foci in the skin, especially poisonous bites, if massage is employed, it must be preceded by thorough local treatment to avoid spreading the infection.

In oedema of the skin and subcutaneous tissue the value of massage depends entirely on the pathological character of the oedema. If the oedema is due to disease of the heart, kidneys or liver, or any other constantly acting cause, one can render the patient no real service by massaging the affected parts, as is often done by medical gymnasts. In this case, however, one may be justified by the prospect of a temporary improvement. But there is no justification for the indiscriminating enthusiast in massage who wants to massage away, not only the subperiosteal cephalohematoma, but also the caput succedaneum of the newly-born, which is for the most part serous, since both these conditions disappear without treatment. In the case of large cephalo-haemiato-mata puncture with antiseptic precautions is much to be preferred to massage. On the other hand, as already mentioned, massage has a real value in getting rid of oedema after constriction. It may also be used after thrombosis for this purpose and to hasten the development of the collateral circulation, but should only be begun after organisation of the thrombus, in my opinion not less than three months after its formation.

Infiltrations, ecchymoses, and haematomata after injuries, especially bruises, arc common in the skin and subcutaneous tissue, as they are in the muscles, and are got rid of by effleurage and friction more easily and surely than by any other means.

The changes in the skin and subcutaneous tissue arising during chronic, or remaining after acute, inflammation should especially be treated by massage.

We have first to consider the infiltrations of rheumatic and traumatic origin in the true skin (Natvig and Gade) and in the cellular subcutaneous tissues. The common infiltrations found in the back of the neck and other parts of the head and neck undoubtedly belong to the former class. They invade the skin and subcutaneous tissue as well as the muscles and nerves, and are generally treated along with myositis and neuritis.

Subcutaneous infiltrations are found in the abdominal wall in women much oftener than in men. They are thought by some to be connected with the wearing of corsets, but according to others are a reflex result of pelvic or abdominal lesions. They are often very tender to pressure. They are distinguished from myositis by their more superficial position and by the functional power of the muscles being normal. On palpation they give the impression of a more "fine-grained" formation than the normal fatty subcutaneous tissue. These subcutaneous infiltrations, which are often called cellulitis, may give rise to the same mistakes in diagnosis which I considered in connection with myositis in the abdominal muscles. Since they give rise to severe subjective symptoms, they frequently come under treatment by massage, but are often slow in yielding to treatment.

Purulent processes in the skin and subcutaneous tissue, as elsewhere, contra-indicate all massage. It would not occur to any intelligent or competent person to treat acne, boils, carbuncles, or erysipelas by massage. But the hardenings and thickenings remaining after such affections may be got rid of by friction and effleurage.

After erysipelas in particular this treatment may be given with great benefit, as Professor Gussenbauer has so well demonstrated. His patient was a man of seventy-two, who, after repeated attacks of erysipelas, presented an elephantiasis-like swelling of the forearm, with the skin thickened, red, and covered here and there by papillary excrescences, with wrist and elbow stiff, and great aching of the arm when hanging down. The condition was such that amputation was justifiably considered. The arm was suspended vertically for four days and nights under injections of morphia : adhesions in the tendon sheaths were freed by passive movements; massage and compresses did the rest, and in three weeks the patient was permanently freed from the aching, swelling, and stiffness of the joints.

I have already mentioned that during scar formation massage has the power of keeping it within certain limits. When the scar is complete, at its best and freest, and still quite recent, strong frietion performed over the whole area with quite small movements of the finger-tips (not to break the skin) can produce atrophy of the scar tissue and make it much thinner. This chiefly comes under consideration it the skin over a large area has been injured by a burn of the third degree, i.e., with destruction of the true skin, when friction is a useful adjunct to gymnastic, orthopaedic, or surgical treatment.

Ulcer of the leg is with great advantage treated by massage along with external medication. Friction is given especially over the edges of the ulcer, which are often much infiltrated and thickened, and even over its whole surface. Effleurage is given over the whole leg. In marked cases of varicose veins with phleboliths, which are generally found in the leg, stroking over the corresponding parts must be performed very cautiously; but even in these cases one can generally continue the stroke more strongly over the femoral vein in the thigh. An elastic stocking should also be used. Effleu-rage should be given at least twice, sometimes three or four times, a day. This often requires caution, but is nevertheless so simple that an intelligent servant can be trusted to do it. It sometimes happens that ulcers which for years have defied all forms of treatment heal within a few weeks under this method.

Some other skin affections may with advantage be treated by effleurage along with other treatment. Effleurage is given cautiously over the affected area, and centrally over the blood vessels leading from it. This is of course more particularly the case with regard to the extremities, and especially with regard to affections of the forearm and leg. Chronic eczema is often healed in this way. Unna has treated lupus successfully, and Murray prurigo by massage. Shoemaker, Rosenthal, and others recommend in acne vulgaris that the ordinary treatment of opening and disinfecting the pustules should be followed by effleurage.

Mezger has treated teleangiectasis of the skin by massage, pressing upon the afferent veins with the fingers of one hand, so that the small vessels become distended with blood, and then crushing them with the thumb of the other hand working from the periphery. When the teleangiectasis extends over the soft parts of the nose Mezger inserts an ivory rod into the nasal opening in order to have a hard surface for friction. After the treatment a hardness remains for some time in the skin and subcutaneous tissue, but no new formation of blood vessels takes place.

Massage in the form of effleurage, light friction, and tapotement is of use, especially if used early in sclerema or scleroderma. The same holds good for sclerema neonatorum found in atrophic infants.

In the earlier editions of my book on massage I recommended a definite form of massage treatment for frost-bite, which is common in Sweden. This treatment consists of effleurage over all four extremities, preferably combined with abdominal kneading for its effect on the blood-pressure and circulation, and has a much greater effect in limiting or averting threatened gangrene than aimless kneadings and vertical suspension of the extremities. I had such a case to treat in Neglinge in 1898. The patient was a workman who, being incapacitated by his daily alcohol and unable to reach his home, took his night's rest in a snow-drift, the temperature being - 22° C. My first decided impression was that the hands and feet were likely to become gangrenous. Meanwhile I ordered effleurage over all four extremities, given simultaneously by four people for two hours (to begin with in a cold room) and repeated several times a day. Abdominal kneading was given at once. The result of treatment was surprising in the extreme. The upper limbs and one leg completely recovered, and only a small part of the tip of the great toe of the other leg became gangrenous. Since then other cases of frost-bite in Sweden have been treated in the same way with excellent results.

Energetic and extensive effleurage has of course the same effect in preventing or limiting local death in cases of gangrene, but can generally only be performed centrally from the gangrenous skin area.