Abdominal massage may be administered to help remedy any constipation which may be present, but its main objective should be to assist the portal circulation. This has been shown to increase the percentage of solids excreted in the urine more than general massage of the whole of the rest of the body.

Hitherto the effect of massage has been considered so far as it aims at securing sedative effect and at assisting the elimination of waste products. That benefit can also be derived directly from the mechanical assistance to the circulation is beyond question.

In the first place, the toning-up of the vaso-motor system in the extremities will secure a more efficient blood supply through them. This ensures a more even blood supply throughout the body, the capacity of the "reservoir" of the blood is thus, as it were, increased, and the work of the heart is correspondingly lessened.

Then, again, every assistance which is rendered to the return of blood to the heart, by affording a vis a fronte, must tend to decrease the vis a tergo which is required to ensure adequate circulation. This affords a further saving in the expenditure of cardiac energy.

As strength and general vitality return, - the result of improvement in the capacity for rest; as the toxaemia decreases, due to the elimination of waste products; as the heart gains in strength, owing to the mechanical assistance we are able to afford to it; - so the general condition of the patient improves. Appetite returns, and with it there is increased assimilation of nourishment, and so strength improves, till, finally, the patient is able once more to resume exercise, by which alone health and strength can be fully restored. Surely, then, in massage, we have a rational treatment for all cases of valvular disease of the heart with the solitary exception of malignant endocarditis. Treatment by rest and drugs without massage is unscientific, in that it aims solely at remedying the main organ affected, and ignores the desirability of treating all the concurrent evils which must inevitably be present, and which, by physical rest alone, must be augmented and even multiplied. Even from the psychical point of view, active treatment in the form of massage must be held as immeasurably superior to rest alone and the regular administration of drugs. When we add to this the increase in comfort which efficient massage is able to convey, that the treatment hour forms the brightest spot in the tedious monotony of a long day, and that undoubted physical benefit can be assured, then we can realise how greatly it is possible to benefit these patients.

Treatment of victims of cardiac trouble by rest can be likened to the treatment of recent injury by immobilisation, the administration of drugs corresponding to the fixation by splintage. But the use of splints (or the administration of drugs) is in no way incompatible with treatment by mobilisation and massage, and by these means we are able to secure adequate rest to the parts which require it, while maintaining the health and vitality of all the other structures. Indeed, it has been proved experimentally that certain drugs have their efficacy improved by the administration of massage.

In the later stages of cardiac treatment the use of the Ber-gonie chair is invaluable, and should always be given a trial whenever practicable. Massage and mobilisation, however, provide a very efficient substitute.

Later still exercises must be prescribed. The brothers Schott have elaborated a special system at Nauheim. There is no reason why treatment should prove less efficacious in the privacy of the home. The exercises consist solely of carefully graduated relaxed and resistive movements, which in turn prepare the way for active movements. Breathing exercises should, of course, be given prominent place in any table of free exercises. These must, however, be regulated with great caution, as injudicious prescription of breathing exercises involves severe strain upon the heart.

Reference must also be made to the "terrain cure," which again can usually be simulated in the privacy of the home. In short, it consists of prescribing a definite dose of walking along paths of varying incline. The "path" can be mapped out on any hill in the country. I have never seen this treatment in progress, so cannot judge how prescription is regulated. No doubt elaborate examinations are made. In practice, at home or in the field, it should suffice to assure us that no excessive strain is being borne, if the patient is never in the least "outof-breath" as a result of any exercise or movement. The object, when once the patient is ready to progress, is to arrange that he shall do in the near future what he could not do to-day without this happening. It should be noted that progress is not by any means uniform. It is a mistake to insist on daily progress whether or no the patient "feels up to it." On an "off" day let him rest, and more will be gained on some not very distant morrow than by causing fatigue to-day.

Throughout treatment a careful watch must be kept for any trace of fatigue. This is shown by altered respiration, by change in pulse or colour, or by restlessness. It is important that the masseur should be able to take the pulse, and should have sufficient experience to note changes therein. This can only be acquired by practice, and it would be well, therefore, if all masseurs familiarised themselves with the normal pulse by examining it in every case treated in hospital or during training. In private work, except in heart cases, such examination might sometimes be regarded with disfavour, and might lead to uneasiness and doubt in the patient's mind.

The treatment of angina pectoris has been referred to in Chapter XXII (The Treatment Of Functional Disorders And Of Other Conditions Of Uncertain Origin)., and also the treatment of arteriosclerosis and its frequent companion, chronic renal disease (see Chapter XXVI (The Treatment Of Constitutional Disorders).).

Fatty infiltration of the heart was considered on pp. 374-376.

Disorders of the venous system may be considered under two headings, varicose veins and thrombosis.

It is difficult to say how, or why, massage treatment should benefit varicose veins. It is sometimes taught that benefit is bestowed by the action of the massage on the unstriped muscle in the walls of the veins. This explanation seems to me to be more than doubtful; first, because there is so little muscle present, and, second, because what there is has been so stretched by the dilatation of the vein that return of function is almost incredible in long-standing cases. The fact remains that assistance can be given. It is probable that in ordinary life the patient never assumes a posture which allows the veins to empty completely, and so their walls remain constantly under tension. Massage can at least relieve the tension temporarily, and this may be responsible for the benefit which it can undoubtedly bestow. Treatment should therefore be given, whenever practicable, after the patient has finally retired to bed for the night. It should consist of the deep-stroking variety in the main, and should be performed slowly, with just sufficient pressure to obliterate the lumina of the vessels. Any more severe pressure can only tend to inflict injury upon the already stretched and weakened walls of the veins. If hard or tortuous, the veins should be left alone, and treatment be confined to areas where it is possible to assist the collateral circulation. Varicose patches should be avoided likewise. In these the venules sometimes rupture spontaneously, so even the lightest form of massage cannot be regarded as free from danger when applied directly to them. The leg during treatment should be supported by pillows, so that the thigh and knee are both flexed to half a right angle. If a bandage is to be applied, this should be done before the position is altered.

The condition of varicose ulcers - even of long standing - can be greatly ameliorated by massage. In addition to general treatment for the circulation, the whole area for some distance around the ulcer should be vibrated with care. The ulcer itself may be covered by gauze and subjected to soft vibration. All scraping of the surface must of course be scrupulously avoided.

(See also p. 196 for description of technique.)

The treatment of thrombosis by massage is a very serious problem. If severe sepsis has been present, it is still more serious. The very life of the patient may be involved by an error in technique, since massage over a vein in which thrombosis is proceeding is calculated to spread the trouble, and, even when the active process is only recently quiescent, injudicious handling may lead to the separation of an embolus.

The signs of thrombosis have been considered (see p. 144), and should be familiar to every masseur.

Whenever this condition is present, recovery depends on the education of collateral channels to take on the work of those which have been obliterated. Occasionally the obstructed vein may function once again by absorption of the clot, but usually the blood finds its way into other channels.

Treatment should be administered with the double objective of aiding the venous circulation and of reducing the oedema which will inevitably be present.

After aseptic thrombosis, such as in the posterior tibial vein after simple fracture in the leg, massage treatment may be resumed with the utmost care and gentleness some four weeks after the cessation of the spread of the symptoms. Active movements may be prescribed about two weeks later. This is conservative treatment: it is wise to be over-cautious when the patient may pay for our rashness with paralysis or even death.

After septic thrombosis, on the other hand, as in femoral thrombosis after confinement (white leg), it is rarely safe to begin massage till two months at least have elapsed. Treatment should consist of surface and very gentle deep stroking - all the muscles, of course, being completely relaxed. Slow, gentle kneading may be given to all structures except to those areas where pressure is likely to be transmitted directly to the damaged vein - e.g., the thigh and anterior part of the leg may be treated if the posterior tibial vein only has been affected. The popliteal space, Hunter's canal, and Scarpa's triangle should all be avoided during treatment, if the vein in these areas has been involved in the thrombosis.

Relaxed movements may be given, but with caution. Active movements may be prescribed from the end of the third month. It is not unusual to hear of patients spending six, and even nine, months in bed, so there is no need to "push" treatment - a process that can only be described as dangerous. "General" massage is rarely safe till the fourth month.

The treatment of hemorrhoids has been considered (see p. 411), and also the various spasmodic conditions which occur in the arterial system (see Chapter XXII (The Treatment Of Functional Disorders And Of Other Conditions Of Uncertain Origin).).