"I would lay stress on the importance of massage being properly applied. The ordinary so-called massage does not, as a rule, have the slightest effect on these deposits. Quite a large number of our patients have been treated by hydrotherapy and massage for weeks or months at other centres without satisfactory results. The form of massage has been the ordinary kind extended over the whole limb or limbs without concentration on the affected tendon or muscle. We find that after a period of three to four weeks' treatment by hydrotherapy and massage, consisting of deep thumbing movements on these areas, followed by deep kneading and upward pressure, the deposits, which can be felt to break up, have disappeared and the pain has vanished. A great saving of time and labour is effected, for the whole limb need not be massaged until the end of the daily process, when the clearing away of the effete products is desired."

I would only add that the frictions should begin very gently, and, as tolerance increases, may become steadily firmer. The presence of nodular thickenings can sometimes be detected more easily if oil is applied to the patient's skin, but its presence is a hindrance rather than an assistance to the performance of the massage.

Captain T. Marlin has treated several cases for me by galvanism, and the result has sometimes been most gratifying. The skin is tested for sensitive "spots" by Faradism. A round needle, attached to a negative pole, is inserted into the spot, and success in selection of the exact spot is held to be proved by reproduction of the pain of which the patient complains.

A current of five milliamperes is then passed through the needle for three to six minutes. The pain gets less during treatment, but may increase after three to four hours' time. The test of success is that the patient should sleep better after the treatment. My experience of the treatment, which is very unpleasant, is so limited that I cannot say how frequently it may be necessary or in what cases it should be applied. My impression is that it is not likely to develop into routine treatment.

Other muscles may be affected in the same way, the commonest being the muscles of the neck. The origin of an attack of stiff-neck ("rheumatic" torticollis) can nearly always be traced either to damp or cold. It may be presumed that the cause is rheumatic. Treatment should follow on the lines suggested above, but the stroking should be performed from above downwards, while kneading should begin near the root of the neck and slowly work upwards.

Pleurodynia, perhaps the most common of the acute forms of myalgia, consists of excruciating pain in the intercostal muscles. Much can be done to relieve it by massage, but we have to rely chiefly on kneading and friction. Stroking should however, precede and succeed these movements.

Any other muscles may be affected, those of the head and of the shoulder regions furnishing examples. Treatment must be conducted on lines similar to those sketched out above.

In all cases of myalgia we are justified in assuming toxicity. If this is true, the more we can assist the elimination of waste products the better. Local treatment may therefore be followed by a short general massage of the four limbs, and abdominal massage and exercises should be considered.

A condition closely allied to myalgia is found in the fasciae - a fibrositis. Presumably the two conditions are often present simultaneously and differentiation between them is impossible. Fibrositis is often accompanied by obesity. The cause is probably the deposit of toxic material in the lymph spaces lining the facial planes. Treatment should be carried out as described for cases of lumbago in its' various stages - acute, sub-acute, or chronic.

Obesity can sometimes be treated most successfully by massage, but caution should be exercised in applying the treatment. One rare form of obesity is accompanied by pain in the areas where the fat is about to be deposited, and, in massage, we have an agency by which the pain can be materially eased.

There are four main classes of obesity. It may be hereditary, when the undue deposit has no effect on the general health, and therefore the aid of massage will not be invoked.

In children it is usually due to concurrent disease, such as anaemia and rickets, which must receive appropriate attention.

Women about the time of the change of life frequently "put on flesh" at an alarming pace. As a rule, the administration of thyroid extract is a more scientifically correct treatment than the application of massage; but, if the patient's health is being affected deleteriously by the deposit, massage can afford material assistance in treatment.

The fourth type of case is the one that usually calls for massage treatment. This may be described as the "gouty" type. It may occur in many different ways, but, roughly speaking, cause and effect may be summed up by stating that injudicious or excessive feeding introduces into the body an amount of nourishment in excess of that required for the expenditure of energy. The excess is the cause of the fatty deposit. This condition is usually encountered in people over forty years of age, and may be very serious and disabling. Two classes of case are commonly met with - the chronic over-feeder; and the man who suddenly alters his habit of life, without altering his dietary to correspond with the decrease in exercise.

The utmost care must be taken to discriminate between two main groups of cases - namely, that in which the vital actions (heart and respiration) are unimpaired, when the patient is frequently said to be suffering from fatty infiltration of the heart; and that in which either or both have suffered, perhaps severely, and the diagnosis is fatty degeneration of the heart. To contrast the treatment, it may be said that exercise for the latter may be fatal; for the former it may suffice to cure.