It is almost impossible that manipulations should be painless, but the pain should be limited to what many patients refer to as a "pleasant ache" or a "nice pain." Should severe pain be caused inadvertently, it can usually be relieved by stroking.

Great care should be taken to regard in treatment the law that deals with the signs of excess. Any decrease in movement, or increase of pain or swelling, as compared with the condition present on the previous day should indicate that treatment must be reduced. The treatment may not have been excessive the day before, as the disease is liable to wave-like variations; but treatment that may be beneficial one day might well prove harmful the next, if some slight exacerbation has taken place during the night.

During the acute phases the utmost care must be exercised; massage should be of the lightest and should aim solely at relieving pain, while mobilisation should be left for a future date. As the attack subsides much benefit can be derived from cautious local kneading of the periarticular structures. Voluntary exercise of all muscles, as occasion allows, is an essential part of all treatment.

Few physicians seem to realise the fact that massage may be invaluable in the treatment of cases of diabetes. Most will recognise that treatment at Aix-les-Bains is powerful for good; but after all, when there, the chief remedial agent is massage. The local water is utilised as a lubricant, it is true, but, as Graham writes, "this is simply another illustration that every substance capable of being rubbed on the human body has had wonderful virtues ascribed to it, and it must be that which is common to them all that does the good - namely, the rubbing." This has been echoed, when writing on another subject, by Sir William Bennett, who says: You may use liniments or not as you like: it is the rubbing that does the good."

It has been proved over and over again that massage has a potent effect on the elimination of waste products. General massage should therefore be administered to the diabetic, particular attention being given to the abdomen, with the idea of assisting the portal circulation.

Diabetic neuritis may be greatly benefited by massage, the pain or numbness relieved, and the irritation or tingling kept in abeyance. If all that massage could effect was alleviation of the torture of the irritation, its administration would be invaluable.

It may be too much to say that massage can permanently prevent the onset of diabetic gangrene; certainly it can postpone it for a very long period of time. Moreover, it can prevent or limit its spread when once established, and can hasten the healing of ulcers on the feet which, without its aid, would never heal. Prevention being better than cure, massage should always be given to assist the circulation in the lower limbs whenever its aid is invoked in the treatment of diabetes. The fact that gangrene is liable to occur should suffice to indicate the care and caution that should be exercised. Deep stroking must be performed with delicacy of touch, and kneading or picking-up should be of the gentlest possible character.

Senile gangrene, probably a symptom of arterio-sclerosis, may be dealt with in a similar manner. As a prophylactic, the use of massage has proved to be most encouraging.

In the treatment of rickets we have to deal with another general disorder of metabolism. It is a disease of the first and second years of life, though occasionally so-called "adult rickets" may develop at about the time of puberty.

The disease is due to faulty nutrition, and may have lasting effects. The child may be lean and "scraggy," or fat and flabby. There is fretfulness, slight fever, and sweating at night. The mother often reports that "baby is tender all over."

The lightest possible stroking over the whole body with warm oil will do much to relieve the sensitiveness, especially if the child is of the "scraggy" type. The liver is usually enlarged and the abdomen distended by this and by flatulence. The child is therefore "pot-bellied," and abdominal massage very delicately performed, should be practised. The legs tend to bow, and so soft is the bone that much may be done to mould them into shape by manipulation during the performance of massage. No attempt should be made to hurry the process. The general tenderness that exists will probably ensure that progress is slow, but in any event the moulding should be performed with all possible gentleness.

A long period of time often elapses before the bones become rigid, and so it is possible to do much for the correction of other deformities which are frequently noticed in chest and back. The child will usually be found to have adenoids, and the tonsils will probably be enlarged. As soon as the patient is old enough breathing exercises should be taught. As a rule these should consist of lateral body-bending exercises with rotation, so arranged as to render the compressed lower ribs prominent. Deep breathing is then encouraged, and the child is taught to dilate that part of the base of the lung which has hitherto been prevented from expanding (see Fig. 150, p. 434). Assistance should be given in the form of an attempt to twist the ribs round while the spine remains fixed. Abbot has shown the extraordinary power of the repetition of the respiratory movements in moulding the chest wall, when the movements are properly directed. Stated shortly, the principle underlying his treatment for scoliosis is to place the patient in a plaster jacket, which is so arranged that the prominent part of the chest wall cannot expand while the receding portion, being out of contact with the plaster case, can do so. The incessant movement of this part of the chest wall, and the comparative immobility of that of the opposite side, not only results in alteration of the shape of the ribs, but also corrects the rotation of the vertebrae. But, if the bones are soft from rickets, this plan is dangerous, as it is likely to result in all sorts of moulding in undesirable and unexpected places. It is for these cases that massage, hand moulding, and breathing exercises should be employed. Though plaster cannot be applied, at least the principles underlying the treatment should be employed. Later on, when the bones are firm, these means are of small avail, and, if deformity is to be remedied, plaster should be used. The greatest possible care is necessary in its application.