General Massage consists of effleurage, petrissage, and tapotement. It comprises massage of the greater part of the extremities and of the trunk, as well as abdominal massage or abdominal kneading, which is, or ought to be, included in it unless any contra-indication is present. The effects produced by effleurage, petrissage, and tapotement, as well as by abdominal kneading, are also produced by general massage, and I refer the reader to what I have already said on the subject.

I have left to this section on general massage reference to some of the effects of the above-mentioned forms of massage, and must now, therefore, state their effect on blood formation, the heart's action, the circulation, and especially on blood pressure and pulse-rate, as well as on metabolism and its processes.

In the first Swedish edition of this book I stated (see "Handbok i Massage," Stockholm, note on p. 269 *) that I had reason to believe that general massage was of use in chlorosis and anaemia, although I could give no definite information on the subject. The reason was that in some cases of chlorosis without any other special treatment a definite increase of the red blood corpuscles and of haemoglobin was found after general massage, which always included an energetic and lengthy abdominal kneading. My observations were, however, few, and only allowed of a surmise. In the Medical News, December, 1893, Dr. J. K. Mitchell, of Philadelphia, recorded his observations on the increase of red and white corpuscles and haemoglobin after general massage, but his cases were not quite sufficient in number to form definite conclusions. Some years later Winternitz, Strasser, and Westheimer found (by examining the finger and the ear) that all thermal and mechanical treatment, applied to the whole or the greater part of the surface of the body, with few exceptions produced an increase of the red and white corpuscles. They considered that the same effect was produced, though in a less degree, by gymnastics. In the Deutsche Med. Wochenschrift, 1902, No. 29, Dr. Erik Ekgren has recorded observations of nine cases of which five were treated by general massage, consisting chiefly of effleurage (? without abdominal kneading), four with only abdominal kneading. General massage or abdominal kneading in each case produced an increase of the multinuclear white blood corpuscles (with a corresponding diminution of the uninuclear elements). The increase was generally a small percentage, but often rose to two figures, in one case to 25 per cent. The blood-count was made ten minutes after the massage ceased, and the increase lasted only in exceptional cases for twenty to twenty-five minutes, and then gradually fell.+ Abdominal massage, according to the tables, appears to have had a stronger effect than general massage without it.

Recently G. Rosenthal has observed that effleurage over one arm produces a marked increase in the number of white blood corpuscles within the same area of the other arm - which he himself ascribes to a change in their distribution in the blood stream. Vibration had the same effect, although not to the same extent; other forms of tapotement and petrissage had the same effect, though to a still slighter extent.

* The translator of the first German edition left out this note, for what reason I know not. It is therefore missing in all the foreign editions I have seen; probably in all. It is to be found on p. 269 of the Stockholm edition of 1888 - 1892, which came out in parts.

+ The increase was probably due to temporary variations in the concentration of the blood.

We may now state with some certainty that general massage, and especially abdominal massage, forms a means of increasing the number of red and white corpuscles and the amount of haemoglobin. For my part, I find it hard to believe that the increase is only in the peripheral part of the circulation.

Most of us consider lymph partly as a transudation or secretion from the capillaries, partly as a product of metabolism in the tissues.

There is much uncertainty both in main points and in detail in regard to the formation of white, and still more so of red, blood corpuscles.

Certain of the white blood corpuscles, the lymphocytes, are probably formed in the "lymphatic reticular tissue," such as is found in the solitary follicles in the tonsils, in Peyer's patches in the alimentary canal, in the Malpighian corpuscles of the spleen, and in the histologically similar lymphatic glands. In all these parts, which consist chiefly of fine connective tissue, the lymphocytes multiply by division. According to Bizzozero and Flemming a similar tissue is found in the marrow of the long bones, in which both red and white corpuscles multiply by division. We do not know whether the thymus gland is concerned in the formation of blood corpuscles.

From these facts it is obvious that by increasing the activity of the circulation one can produce an increase of blood corpuscles by means of massage, especially by abdominal kneading, or by eflleurage over the whole body.

Without committing myself to the old nervous or to the new muscular theory of the heart-beat, I would remind my readers of the nerves of the heart. These consist (1) of fibres from the sympathetic ganglia in the neck; (2) of the vagus with certain ganglia lying in the substance of the heart. The sympathetic nerves of the heart are "accelerator," and their stimulation increases the frequency and force of the heart-beat. But the vagi, which are stimulated more easily and quickly, and above all more frequently, in a reflex way than the sympathetic nerves, slow and weaken the heart-beat; strong stimulation of the vagus brings the heart to a standstill in diastole. According to Heidenhain, the vagus contains also accelerator and strengthening fibres. A sympathetic curve has many small low pulse waves; a vagus curve has fewer but larger pulse waves, with a marked difference in pressure between systole and diastole; it shows marked rise and fall.