The Art of Massage
J. H. Kellogg, M.D.
1895
THE PHYSIOLOGICAL EFFECTS OF MASSAGE
 

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    The interest in the therapeutic applications of massage which has increased so rapidly within the last twenty years has led to numerous investigations by able physiologists for the purpose of determining with exactness the physiological effects of the various procedures included under the general term massage, and thus obtaining a correct basis for their therapeutic use.  Many of these experiments have been repeated and verified by the writer in the physiological laboratory under his charge in connection with the Battle Creek Sanitarium, and some of the results will be recorded in an Appendix, in addition to this brief summary of the conclusions which have thus far been obtained by those who have most carefully studied the subject.  These investigations have established beyond all possibility of question, that massage affords one of the most effective means of influencing the functions of the human body.
    Experiments clearly show that every function of both animal and organic life may be powerfully influenced by some or all of the numerous procedures of massage.  The various effects produced may be included under the following heads: -

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    1.  Mechanical, in which the tissues are wholly passive, being simply acted upon in a mechanical way by the hand of the manipulator, as in the movement of the blood and lymph in the venous and lymph channels, or the restoration of a displaced viscera to its normal position.

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    2.  Reflex, in which the peripheral and central portions of the nervous system, both cerebro-spinal and sympathetic are chiefly active, an impression made upon the nerve ends of the sensory or afferent fibers connected with the nerve centers of the cerebro-spinal and sympathetic systems being transmitted to the related centers, where new activities are set up, resulting in the sending out of nerve impulses by which vital changes are effected, not only in the parts directly acted upon, but in related parts.

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    3.  Metabolic, in which important modifications occur in the tissue activities both of the parts directly operated upon and of the body as a whole, as the result in part of the direct mechanical effects of massage upon the tissues, and in part of the reflex activities set up by it.
    In a brief manual like this there is not space to consider in detail the modus operandi of all the different effects of massage. We must be content with a simple enumeration of the specific effects upon the principal systems and functions of the body.
 

Effects of Massage upon the Nervous System.

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    All the different procedures of massage produce a decided effect upon the nervous system through the influence of the manipulations upon the nerve endings of both the cerebro-spinal and the sympathetic -nerves, which are found in so great abundance in the skin and muscles-the former in connection with the special senses of locality, temperature, pressure, and
weight; the latter more especially in connection with the glands, blood vessels, and thermic mechanism located in the skin and muscles.

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    1. Direct Stimulating Effects. - Vibration and nerve compression may be made to act directly upon nerve trunks, thereby causing powerful stimulation not only of the peripheral nerves but of all the nerve centers with which a nerve trunk is connected.

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    Friction is an effective means of exciting languid nerves.

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    Light percussion simply increases nervous irritability, while strong percussion may cause so great a degree of nervous irritability as to exhaust the nerves, and thus produce a benumbing effect.

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    Tapping, slapping, clapping, and hacking are the most effective means of exciting nerve trunks.
    Beating and vigorous hacking are especially useful for exciting the nerve centers, and hence are especially applicable to the spine.  The nerve centers may also be directly excited by deep vibration and by strong percussion.

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    2. Reflex Effects - The reflex effects of massage are very remarkable and exceedingly interesting. All the procedures of  massage produce powerful reflex effects. Some of the most striking effects are produced by very light stroking, especially when applied to certain reflex areas. (See Reflex Stroking.)

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    Percussion and vibration are also powerful means of producing reflex effects, which include not simply muscular action, but increase or decrease of vascular and glandular activity, and general tissue change.

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    3. Sedative Effects. - The sedative effects of massage are equally as marked as the stimulating effects. Strong percussion relieves pain in the same manner as does strong faradization, by tiring out and thus obtunding nerve sensibility. Pinching produces an anaesthetic effect in essentially the same way.The physician always pinches the skin before introducing the
hypodermic needle.

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    Sedative effects are also produced by gentle stroking -the so-called hypnotic effect, doubtless, through reflex influence upon the nerve centers.

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    Very marked sedative effects are produced by derivative friction and kneading. Centrifugal friction (rubbing down) diminishes the blood supply of the brain, and hence lessens cerebral activity.

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    Light friction over a deep-lying organ diminishes its blood supply by increasing the activity of the overlying vessels, thus causing the blood to go around instead of through it.

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    Massage of the soft parts above a joint, and movements of the next joint above, relieve pain by emptying the lymph and blood vessels of the part.

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    4. Restorative or Reconstructive Effects. - Mental fatigue is relieved by massage, through its effect upon the circulation and the eliminative organs. The toxic substances produced by mental activity, are more rapidly oxidized and removed from the body, while the hastened blood current more thoroughly repairs and cleanses the wearied nerve tissues.

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    General reconstructive effects are experienced by the entire nervous s stem through the improved nutrition induced by massage.
 

Effects of Massage upon the Muscular System.

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    Massage, when skillfully administered, has to do chiefly with the muscles. That form of manipulation which consists simply of skin-pinching excites the nervous system and the surface circulation, but has little influence upon the muscles. When  we reflect that the muscles constitute one half of the bulk of  the body, and receive one fourth of all the blood of the body, it is at once apparent that any procedure which acts directly  upon them must have a decided influence upon the whole body.

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    Although the muscles constantly receive a certain blood  supply, this supply is comparatively small except during activity; consequently, it may be said that the muscles are well fed only when exercising." When the muscle is inactive, the blood goes around it rather than through it ; but the moment activity of the muscle begins, there is a great increase in its blood
 supply, even before any acceleration in heart activity has occurred.

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    Massage may serve to a considerable extent as a substitute for exercise by increasing the blood supply of a muscle, just  as exercise may be considered a sort of massage, through the pressing and rubbing of the muscles against each other. When properly administered, the manipulations of massage act upon the muscles in such a way as to produce a suction, or pumping effect, pressing onward the contents of the veins and lymph channels, and thus creating a vacuum to be filled by a fresh supply of fluid derived from the capillaries and the tissues.

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    Specific Effects of Massage upon the Muscles. - Massage in its specific effects upon the muscles, may be said to accomplish the following results : -
    1. To Encourage Nutrition and  Development of the Muscles. The increased blood supply of the muscle induced by massage naturally improves its nutrition. Experience shows that, when systematically and regularly employed, massage produces an  actual increase in the size of the muscular structures. The muscle is also found to become firmer and more elastic under its influence.

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    Massage feeds a muscle without exhausting it, in which respect it differs from exercise ; nevertheless, it is not a complete substitute for exercise, for the reason that exercise brings into active play the whole motor mechanism - nerve center, nerve, and muscle - while massage affects chiefly the muscle.

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    The improvement in the nutrition of the muscle, as regards increase in size or firmness, is seldom noticeable for the first three or four weeks, and the most marked effects should not be expected until after two or three months.

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    2. To Excite Muscular Contraction. - A smart blow upon a muscle is one of the ways by which contraction may be excited. By a succession of blows, one following another with sufficient rapidity, tetanic contraction of a muscle may be induced.

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    Strong vibration will also cause tetanic contraction of a muscle; but very rapid and strong vibrations are required to produce tetanus. In voluntary tetanus (ordinary muscular contraction) the number of impulses received by the muscle per second is ten to twenty.  It is evident that the rate of vibration required for producing tetanus must be as great or greater. and consequently mechanical means of some sort must be applied, as the highest rate of movement which can be communicated by the hand directly is ten to twelve double movements per second.  A vibratory apparatus which I have had in use for many years, and which produces decided muscular contractions, has a movement of sixty per second.

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    In certain cases, muscular contraction may be induced more readily by the application of percussion than by the faradic current.

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    3. To Increase Electro-excitability of the Muscle. - Numerous experiments have shown that massage increases the electro-excitability of a muscle, as indicated by the fact that a smaller number of milliamperes of current is required to cause contraction of the muscle after massage than before.

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    According to Kroneker, however, a muscle is less easily 'tetanized after massage than before, but its power of action is greatly increased. An abnormal degree of muscular irritability is certainly relieved by massage.

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    This effect of massage may be advantageously utilized as a preparation for applications of electricity in cases in which the electro-excitability of a muscle is diminished by trophic changes, as in infantile paralysis.

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    4. To Remove the Effects of Muscular Fatigue. - Ranke, Helmholtz, Du Bois-Raymond, Mosso, and more recently, Abelous, have conclusively shown that special toxic substances are produced as the result of muscle work, and that the phenomena of fatigue are due to the influence of these substances upon the nervous and muscular systems.

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    Abelous has shown that the first effect is a sort of auto-curarization, or paralysis, of the terminal motor plates of the nerves which actuate the muscles, while in advanced fatigue the muscle itself is exhausted by the consumption of the material (glycogen) necessary for work.

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    The fact that a fatigued muscle can be restored to full vigor at once by simply rinsing its vessels with a normal saline solution, as shown by Ranke, demonstrates the toxic character of the phenomena of fatigue. Bowditch, Bernstein, and others have shown that the nerve itself is indefatigable.

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    Zabloudowski has shown that frogs completely exhausted by faradization of the muscles, although not restored by fifteen minutes' rest, were revived at once by massage, and were even able to do twice as much work as before.

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    In another experiment, a man lifted with his little finger, one kilo (2 1-5 lbs.) 840 times, lifting the weight once a second. The muscles of his finger were then completely exhausted.  After five minutes' massage he was able to lift the same weight 1100 times, and his muscles were even then not greatly fatigued.

36
    The Sandwich Islanders employ massage under the name of lomi-lomi as a means of, resting fatigued persons, and sometimes even apply it to restore an exhausted companion when swimming long distances in company. An intelligent native Maori informed the writer that the same method is used by the natives of New Zealand to relieve cramp resulting from cold when swimming in the sea. The term used for massage among the Maoris is romi-romi, the literal meaning of which is the same as petrissage in the French.

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    The stiffness and soreness of muscles which occur from so called consecutive or secondary fatigue resulting from over-exercise, is also relieved by massage. It should be remembered, however, that secondary fatigue may be produced by too vigorous an application of massage in a person not accustomed to it, especially in those who are very fleshy.

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    Muscular Electricity. - Physiological experiments have demonstrated that with each muscular contraction an electrical discharge takes place, and Mervy has shown that a muscle is a sort of electrical accumulator, electricity doubtless being generated by the muscular and thermic activities which are constantly present in the muscle. As an accumulator it is auto-excitant, and may also be excited by induction or by contact. In this way the muscles of the person masséed may be favorably influenced through induction from the more highly charged muscles of the masseur. This influence, however, must be very slight, and its therapeutic value can scarcely be said to be established.

39
    Effects of Massage upon the Bones, Skeleton, and Ligaments. - That massage is capable of influencing such hard structures as the bones, ligaments, and cartilages, is  clearly demonstrated by numerous facts and observations. A bone has essentially the same blood supply as its overlying  muscles. It is for this reason that the same exercise which causes increase in the size of a muscle, at the same time induces growth in the bone to which the muscle is attached. The bones and joints of persons who are much addicted to exercise are decidedly larger than those of persons who have made little use of their muscles. This is especially noticeable in comparing the large, strong hand and knotty knuckles of the laboring man with the puny band and straight, slender fingers of the man of sedentary pursuits.

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    The blood vessels and lymphatics are largest in the vicinity of the joints, and the change of fluids effected by joint movements, resulting from the action of the muscles upon the bones, necessarily produces increase in the nutrition of the parts, and consequently an increased growth in the cartilages, ligaments, and other structures of the joint.

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    It is now known that the red matter of the bones is the blood  forming tissue of the body. This fact gives a new importance to massage, since the acceleration of the circulation of the blood through the muscles must improve the nutrition of the bones as well as of the muscles, thus favorably influencing the blood-making processes both as regards the quantity of the blood produced and its quality.

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    Effects of Massage upon the Circulation. - Massage profoundly affects the circulation, both general, and local, its effects differing, however, according to the mode of application and the part acted upon. General massage increases the rate and the force of the heart beat, as does exercise, with the difference that it does not raise the arterial tension as does exercise, and does not accelerate the heart to the same degree, though producing a full, strong pulse. This is due to the fact that the. influence of massage is chiefly upon the peripheral circulation.

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    The vigor of the circulatory activity is increased not only in, answer to the greater demand for the removal of the poisons resulting from oxidation as in exercise, but through the mechanical assistance afforded by massage, in moving the blood forward, in the venous and lymph channels, and in setting up reflex activities whereby the small vessels are dilated and their activities quickened. The reflex influence of massage acts as a tonic for the heart, while the dilatation of the vessels decreases the resistance so that the heart acts more freely and efficiently in performing its functions.    Recent experiments by Brunton, verified by the author, show that general massage produces at first, but briefly, a rise in arterial pressure.

44
    Locally, the effect of massage is to produce an active hyperaemia of the part. Under the influence of massage the blood vessels become more active, pumping forward the blood into the veins, through which its flow is assisted materially by the manipulations. The increase of blood is usually accompanied by reddening of the surface and an increase of warmth, sensibility, and general vital activity.

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    Light percussion of the surface causes contraction of the blood vessels of that portion of the skin acted upon. Strong percussion very quickly produces dilatation of the blood vessels which may even amount to paralysis. Light percussion, if sufficiently prolonged, also produces dilatation.

46
    When applied to a reflex area, percussion doubtless also excites the circulation in the vessels of the related nerve centers.

47
    Massage, of the abdomen slows the pulse by raising the general blood pressure. This is accomplished both by the stimulation of the abdominal muscles, thus increasing the intra-abdominal pressure, and also by the stimulation of the vaso-constrictors of the abdominal vessels.   At the same time, a collateral hyperaemia of the skin and the abdominal muscles is produced. and thus visceral congestion is diminished.

48
    Massage has chiefly to do with the circulation of fluid in the veins and the lymph channels, since these are more readily accessible from the surface than the arteries.

49
    Friction acts chiefly upon the superficial veins, while petrissage and other forms of deep kneading act upon the deeper vessels as well.

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    Indirectly, the portal and pulmonary circulations are also influenced by massage. Massage of the extremities, for example, especially if concluded with centrifugal friction, may relieve congestion of both the portal and the pulmonary systems.

51
    Massage of the legs acts more directly upon the portal system, while massage of both extremities favorably influences the pulmonary circulation in case of congestion of the lungs.  Massage of the arms and legs also acts derivatively upon the brain and spine. For derivative effects upon the brain, however, care should be taken to avoid such exciting procedures as percussion and reflex stroking.

52
    Massage also has a powerful effect upon the circulation by promoting the action of the diaphragm, which serves efficiently as a pump in assisting the circulation, as well as in carrying on the process of respiration. M. Camus has shown by experiments upon dogs that the increase either of the rate or the depth of respiratory movement increases the flow of lymph in the thoracic duct. The same has been shown in regard to the blood circulation by numerous investigators.

53
    The influence of massage upon the lymph circulation is especially worthy of attention. The lymph vessels drain the tissues of waste and toxic substances, and prevent clogging from wandering cells. Lymph channels are most abundant in the subcutaneous tissue and in the fascia which cover and lie  between the muscles, so that 'these vessels are mechanically acted upon in massage, especially by friction and kneading  movements.

54
    That massage and exercise of muscles greatly increase the flow of lymph has been repeatedly demonstrated by experiments upon animals, as, for example, it was found that the flow in the lymph vessels of a dog's leg nearly ceased when the animal was quiet, but as soon as the limb was exercised or massaged, the flow of lymph began again (Reibmayr).

55
    It has also been shown that the flow of lymph from a limb in a state of inflammation was very easily induced, and was seven or eight times greater than from a sound limb. A swollen limb was found to diminish during the flow of lymph (Lassar).

56
    The same author has shown that massage of a lymph gland increases the outflow of the fluid. Deep massage applied to a limb diminishes its size. The central tendon of the diaphragm contains a large number of lymph channels. The diaphragm may be regarded as a great lymph pump, since by its rhythmical movement, the lymph channels are alternately dilated and
contracted.

57
    Hoffinger has shown that the absorptive power of the peritoneum is greatly increased by massage. In experiments upon rabbits, the peritoneum was found to absorb under the influence of massage twice as much water in an hour as without massage.

58
    An experiment made by Mosengeil, an eminent German physiologist, graphically demonstrates the influence of massage in promoting absorption. The joints, of rabbits were injected with ink.  Massage was applied to some of the rabbits and not to others. In the cases subjected to massage, the swelling which was produced by the injection rapidly passed away. When the rabbits were killed, some months afterward, it was found that the ink had entirely disappeared from the joints which had been masseed, and was found in streaks between the muscles, and accumulated in the lymphatic glands, indicating the course of the lymphatic channels. In cases in which the joints were not masseed, ink was found in the joints, but none in either the muscles or lymphatic glands. This result affords a striking illustration of the value of massage in affections of the joints accompanied by exudate.

59
It is through its power to promote absorption that massage is of great value in the treatment of local oedemas, general dropsy, and ascites.

    Effects of Massage upon Respiration. - These effects may be thus enumerated: -

60
    1. Increase of Respiratory Activity. - Massage, as does exercise, increases the depth of the respiratory movements. This is doubtless in some measure due to the reflex influence of massage, but must also be attributed in part to its effect in  bringing into the circulation waste products requiring elimination through the lungs, and in increasing oxidation, or CO2, production, which necessarily accompanies the increased heat production resulting from the effect of massage upon the muscles.

61
    2. Increase of Tissue Respiration. - It should be borne in mind that the function of respiration is not confined to the lungs. Respiration begins and ends in the lungs, but the most important part of the process is effected in the intimate recesses of the tissues themselves.

62
    Massage is certainly a most efficient means. of increasing tissue metabolism, by which oxygen is absorbed by the tissues and CO, taken up by the blood. This process takes place chiefly in. the muscles, through the oxidation of the glycogen, of which they contain one half the total bodily store. Hence  it is that massage, by acting directly upon the muscles, increases the tissue respiration by promoting circulation and general tissue activity.

63
    In thus promoting the depth of respiratory movement and the intensity of tissue respiration, massage profoundly affects all the bodily functions. Through the increased lung activity  there is also increased circulation, as the lungs materially aid  the heart in the circulation of the blood. Increased activity of the diaphragm serves to pump both blood and lymph toward the heart with greater vigor.  Digestion, liver action, and other of the vital functions come in for their share of benefit in the increased vigor and efficiency of the respiratory process.  The functions of the brain are more easily performed on account of the more perfect movement of venous blood and the   better supply of oxygen received.

64
    Influence of Massage upon the Heat Functions of the Body. - The heat functions of the body being so intimately connected with the circulation and general tissue activity, it is clear that any agent which profoundly affects the latter must also affect the former proportionately. The heat functions consist of three distinct processes, - heat production, heat elimination, or dissipation, and heat regulation. Massage materially influences all three of these processes.

65
    The muscles are the chief seat of heat production in the body, containing a great store of glycogen and a special mechanism which, under the influence of the nervous system, gives rise to increase or decrease of oxidation, or combustion of the glycogen. The muscles may be considered as the furnace of the body. During activity, heat production is very active; while during rest, it is considerably diminished. In fever there may be either a great increase of heat production or simply a loss of heat regulation, or both conditions may exist. It is thus evident that those procedures of massage which especially concern the muscles, such as different forms of deep kneading and strong percussion, must exert a powerful influence upon heat production.

66
    By actual observation it has been shown that massage of a muscle, as well as exercise, may cause a rise of temperature amounting to several tenths of a degree Fahrenheit. The importance of this fact will be recognized when it is recalled that four fifths of all the food eaten goes to the production of heat, only one fifth of the force represented in the food reappearing as work or energy. This explains the enormous increase of CO2 in connection with muscular exercise. The quantity of CO2, eliminated during vigorous muscular effort sometimes rises to nearly five times the usual amount. Muscular waste and weakness in fever is chiefly due to the consumption of the glycogen, which occurs under the influence of the toxic substances present in the tissues during febrile states.

67
    The continued activity of the muscles in heat production, even when the body is. at rest, is doubtless due to the slight muscular activity constantly present as so-called muscular tone.

68
    Winternitz has shown that under some circumstances heat elimination by the skin may be nearly doubled (increased ninety-five per cent) by friction. He accordingly recommends friction, in connection with the cold bath, for reducing temperature in fevers.

69
    Celsus, the famous old Roman physician, recommended rubbing in fevers when the surface was cold, although be carefully interdicted rubbing in fevers at other times. The increased heat dissipation resulting from massage is directly due to the increased circulation of blood in the skin. The higher the temperature of the skin the more rapid will be the dissipation of heat from the body. The skin is the principal means by which the blood is cooled, the heat brought from the interior to the surface being dissipated by radiation, conduction, and  especially by the evaporation of water poured out of the skin by the sweat glands.

70
    Massage, by dilatation of the blood vessels and acceleration of the peripheral circulation, brings an increased quantity of heat to the surface, and at the same time, through increasing the blood supply and by reflex influence upon the sympathetic nerves, it induces increased activity of the sweat glands, which leads them to pour out an increased amount of perspiration. Thus heat dissipation is increased both by radiation and by evaporation as the result of the application of  superficial massage.

71
    It thus appears that bodily temperature may be either increased or diminished by massage, since by kneading the muscles we may increase heat production, while by friction we  may increase heat elimination. It is particularly important to remember that when massage is applied for the purpose of increasing heat dissipation, only such procedures should be  adopted as will act upon the surface alone, since any manipulation of the muscles will increase heat production.

72
    A small amount of heat is communicated to the surface by the hand of the manipulator, and a further small quantity is generated by the friction of the hand upon the surface; but these sources of heat are too small to deserve more than mere mention.

73
    Another point worthy of notice is the fact that while general massage increases heat production, it does not necessarily increase the bodily temperature, for the reason that the increase in heat production may be more than balanced by the increased dissipation of heat. For example, in a case in which general massage increased the surface temperature 1.40 F., the rectal
temperature fell 0.80 F.

74
    Abdominal massage, however, exercises an effect the opposite of that of general massage. Massage of the abdomen may cause a fall of surface temperature of 0.20 F., while the rectal temperature rises 2.20 F.

75
    Effect of Massage upon Digestion. - There is no single function which may be more clearly demonstrated to be directly encouraged by massage than digestion. By its  judicious application, the digestive process is promoted in  several ways : -

76
    1. By Improving the Appetite. - The general improvement in nutrition occasioned by the removal of waste and the acceleration of the blood and lymph circulations, creates a demand for an increased supply of nutriment which nature  manifests by an improvement in appetite.

77
    2. By Promoting Secretion of the Digestive Fluids. - Massage, especially abdominal massage, through its reflex influence upon the glands and circulation of the stomach and intestines, promotes the production of the digestive fluids in sufficient quantity and quality.

78
    3. By Promoting Absorption of  the Products of Digestion. - Hopadze has shown that massage of the abdomen, for even so short a time as ten minutes, applied at once after eating, diminishes by fifteen to seventy-five minutes the length of time the food is retained in the stomach.

79
    Hirschberg declares that massage of the abdomen hastens the passage of food from the stomach even more efficiently than does either exercise or electricity.  This fact the writer has frequently demonstrated.

80
    4. By Aiding Peristalsis. - Massage not only aids the absorption of food from the stomach, and its passage from the stomach into the intestine, but also excites the reflexes by which, the alimentary mass is moved along in the small intestine to the colon, and finally discharged from the body.  Indeed, massage has no rival in its efficiency as a means of promoting intestinal  activity.

81
    Influence of Massage upon Nutrition, Haematogenesis, and Phagocytosis. - That  massage encourages the  blood-making process is demonstrated by the rapidity with, which the number of red blood corpuscles and the amount of haemoglobin increase in the blood under the influence of this therapeutic means in cases of anaemia.  The value of this fact can scarcely be over-estimated.  The blood is one of the most important of all the tissues of the body.  The total amount of blood contained in the body is about ten pounds, each cubic millimeter of which contains from four and a half to five million corpuscles, making in all 32,500,000,000,000 - more than twenty thousand times the entire population of the globe.  These little bodies have a combined area of nearly 2900 square meters, or more than 3100 square yards - equal to a square nearly 175 yards on each side.  When we consider that this enormous area of blood must pass through the lungs every twenty-two seconds in order to secure the proper amount of oxygen for the tissues, it is readily apparent how great a loss must be suffered when the quantity of blood is diminished ten to twenty or even seventy-five per cent, as in cases of anaemia, and also the great gain effected by a like increase in the number of corpuscles, or oxygen carriers.
    Another important influence of massage upon the blood which has recently been noted is the immediate increase in the number of corpuscles produced by a general application of massage.  Winternitz pointed out, several years ago, the interesting fact that by the application of cold water to the surface in such a way as to secure vigorous reaction, the number of corpuscles could be immediately increased from twenty-five to fifty per cent. In one case an increase of more than 1,800,000 corpuscles was noted within half an hour after the administration of the cold bath.

82
 Winternitz also showed that exercise has a like effect, and Mitchell, of Philadelphia, has proven the same for massage, and the author has confirmed the observation.

83
    It is not to be supposed, as is remarked by Winternitz, that this sudden increase of blood corpuscles is due to a new production of blood cells ; the apparent increase in numbers is due to the sudden bringing into the circulation of a great number of corpuscles which had previously been retained in the large vascular viscera of the interior of the body, especially
the spleen and liver.

84
    Quincke has noticed that the corpuscles accumulate in the capillaries of the liver and spleen in great numbers just before  they are disintegrated, which naturally leads to the suggestion that the corpuscles set free by massage, and restored to usefulness by being brought into circulation, are at the same time  rescued from destruction by the organs devoted to this work in the body.
    Some experiments conducted under the author's direction  for the purpose of determining the influence of massage upon  the blood, show an increase of from three to seven per cent in  the red cells, and from forty to eighty per cent in the white  cells. The increase in the blood-count usually became apparent  within thirty minutes, and lasted from an hour and a half to  two hours. When massage is applied to persons in health , the  effect upon the blood-count is, of course, temporary, but when  the application is made to persons whose blood-count is deficient, the increase continues for several hours; and if the application is repeated daily, there will be noted a permanent increase in the blood-count from day to day.  In this regard the effect of massage is precisely the same as that of cold applications.  By the combination of these two potent measures,- short cold applications followed by massage,- the composition of the blood may be more rapidly and favorably influenced than in any other known way.

85
    Phagocytosis.-This interesting phenomenon, the complete demonstration of which was worked out by Metchnikoff in Pasteur's laboratory, is influenced by massage to a remarkable degree.  In the case of exudates in parts which have suffered from inflammatory processes, the removal of the exudate depends first upon its solution.  This is effected by the white blood-corpuscles, which actually digest the inflammatory products, thus setting them free so they can be carried off by the venous and lymph currents.
    Phagocytosis is also the principal means by which the body antagonizes an invasion of foreign microbes which always takes place in connection with infectious disease.  Microbes of various sorts, and even animal parasites  such as the plasmodia of malaria, are captured and destroyed by the white blood corpuscles.  It is, indeed, through the action of these blood cells that the vital current is kept free from foreign matters of various kinds.  They seem to be, in fact, a sort of vital patrol which march up and down the highways of the body, resisting and destroying intruders of various sorts.
    It is evident that massage, as already pointed out (81-83), by bringing into circulation an increased number of blood cells, must greatly increase the resisting powers of the body.  It is especially worthy of notice that while both the red and the white corpuscles are greatly increased by massage, the white corpuscles are increased in much greater proportion than the red ones.

86
    Massage is also valuable as a regulator of the nutritive processes.  Hopadze has proven that massage increases the assimilation of nitrogenous food substances, while Zabludowski has shown that massage both diminishes the weight of very fleshy persons and increases the weight of badly nourished persons, giving increased appetite and sleep.  He showed that these effects continue not only during the treatment but for some time afterward.

87
    Influence of Massage upon Elimination. - The chief effects of massage upon elimination are: -

    1. To Improve Elimination. - In general it sets waste matters free, by encouraging oxidation, by encouraging cell exchanges by which the waste matters are poured into the blood and the lymph currents from the tissues, and by stimulating the flow of the venous blood and the lymph, as well as by promoting general activity of the circulation, thus bringing the waste matters in contact with the organs devoted to their elimination.

88
    2. To Encourage Activity of the Liver. - The liver requiring oxygen in the various branches of its work as an eliminative organ, its action is greatly encouraged by the increased amount of oxygen brought into the blood by massage.  The .increased activity of the portal circulation produced by abdominal massage especially aids the liver.

89
    Hepatic activity may also be directly stimulated by the application of massage to the liver-especially by vibratory .movements and percussion applied over the organ.  The fact is .worthy of notice that not only hepatic activity but renal efficiency depend upon the integrity and activity of the hepatic cell, which, when stored with glycogen, is capable of transforming leucomaines and various other toxic substances normally produced in the body, into less toxic forms, preparing them for elimination by the kidneys, and also actually destroying ptomaines and other alkaloids which may be taken in with the food or generated in the alimentary canal.  Massage, by promoting these important activities in the liver, not only aids elimination through both liver and kidneys, but contributes to purity of blood by the destruction of poisons.

90
    3. To Encourage Renal Activity. - That massage aids renal, activity has been actually demonstrated by experiments upon both dogs and human beings. Abdominal massage frequently gives,.rise to, a copious discharge of newly formed urine, although massage of the back or loins does not produce the same effect.  Abdominal massage doubtless promotes kidney activity through its influence upon the lumbar ganglia of the abdominal sympathetic and the solar plexus.

91
    In experiments made upon a dog, it was observed that massage of the legs also promoted renal activity.  The increased secretion of urine was, however, observed to be but temporary, probably because the quantity of fatigue-poisons in the body, the removal of which was especially aided by massage, was soon exhausted.  It was found that the same effect was again noticeable after tetanizing the leg, whereby a new quantity of fatigue-poisons was produced.

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    4. To Promote Activity of the Skin. - The activity of the skin is promoted by massage, both in the direct stimulus of the sweat and sebaceous glands and the hair follicles, and also in the reflex influence upon the vasomotor nerves whereby an increased supply of blood is brought to the skin, thus promoting and continuing the glandular activity directly excited.  An evidence of this stimulation of the skin as the result of massage is to be seen in the reddening of the surface; the increased perspiration, which may be so great as to interfere with the manipulations; the increased production of oil, which is particularly noticeable in cases in which the skin is abnormally dry at the beginning of a course of treatment; and the increased growth of hair, especially upon the legs and arms.  Winternitz has shown that friction of the skin increases the elimination of water sixty per cent.

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    When it is remembered that the skin is an organ of respiration as well as perspiration, its increased activity must be regarded as one of the most valuable effects of massage.

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    It is also noticeable that massage of the skin increases its reactive power and so gives it increased ability to defend itself against changes in temperature, weather changes, etc.

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    Local Effects of Massage. - The local effects of massage may be briefly stated to be: 
    1. Increase of blood and lymph circulation.
    2. Increase in both constructive and destructive tissue change.
    3. Absorption of waste or effused products.
    4. Development of the muscles, ligaments, and other structures acted upon.
    5. Increased heat production and tissue respiration.
    6. Reflex or sympathetic effects upon the vasomotor centers, and through them upon the large internal organs,-the liver, spleen, stomach, intestines, kidneys, and the general glandular system of the whole body.