To all who have occupied themselves at all with abdominal diseases, and especially with neuroses of this group, it is clear that at present it is not possible definitely to decide the effect of massage on these still very obscure forms of disease. All we know is that abdominal kneading in certain cases of sensory, and probably also of motor, disturbances has proved beneficial.

In the literature of this subject there are many statements as to the good effects of abdominal massage on nervous dyspepsia, the value of which is considerably lessened by the fact that this term is as yet indefinitely used. Personally I am inclined to believe that at present there is nothing which can throw full light upon the effect of massage per se on purely nervous dyspepsia. The dyspeptic symptoms by which people who suffer from habitual constipation are often troubled disappear when evacuation becomes normal, but these dyspepsias ought not, in my opinion, to be counted as purely nervous. Among patients who have undergone the Weir-Mitchell treatment with great benefit I have, however, seen the symptoms disappear of what is rightly called purely nervous dyspepsia, but the Weir-Mitchell treatment contains other important factors besides massage.*

Concerning massage treatment of the remaining abdominal neuroses, still so incompletely understood, we know very little.

The very painful condition which is often found in neurasthenics, and exactly the same dietetic conditions, and on account of the impossibility of controlling what leaves the stomach at the pylorus, etc. In order to be of any value the examination must be continued a long time. One must examine the gastric juice for some time every day an hour after the usual test-meal (consisting of a cup of tea without sugar or milk and some wheaten bread) without massage, and examine again later under exactly the same conditions with the addition of massage, and it is not improbable that the latter analysis will show on the average a larger quantity of hydrochloric acid.

* The technique of massage in stomach neuroses is the ordinary "abdominal kneading" described above. As is well known, Burckardt found in nervous dyspepsia puncta dolorosa corresponding to the superior hypogastric plexus (which is found by pressing in in the middle line just below the umbilicus against the fourth and fifth lumbar vertebrae between the common iliac arteries). Pressure here causes pain, radiating from the solar plexus or pit of the stomach even up to the neck and head, to which Burckardt attributes a certain diagnostic meaning. Personally I have never troubled to massage over this point, but remind my readers of it because such an effect may possibly be of some value.

Neither is it possible to give a satisfactory explanation of certain other allied disturbances. It is certainly true that such patients have been cured by abdominal massage. But who shall take upon himself to say to what influence the improvement was due ? In many cases these abdominal neuroses are combined with general neuropathic or psychopathic conditions. It is difficult to estimate the importance of hypochondriac ideas which may be present; a certain amount of simulation comes into play,* and external psychical influences cannot entirely be excluded, etc. I have treated by abdominal massage with good results highly "neurotic" people handicapped by heredity, and have been successful both in cases of anorexia and hyperexia. It is, however, impossible to state the kind of influence which makes a patient eat after he has for some time taken it into his head that he cannot eat, or which causes someone to eat moderately who, as a result of some influence from the central nervous system, has for some time consumed daily enormous quantities of nourishment. Massage in these cases works in the same way as, for example, in the case of joint neuroses.

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The liver, on account of its position immediately under the diaphragm covered by the lower part of the chest wall, is very little accessible to massage. But its circulation may be acted upon by means of active and passive movements, especially those movements which take place in the lumbar spine, trunk-rolling, side-bending, etc. By these the portal circulation is affected in two quite different ways. In all movements which lengthen the inferior vena cava its capacity is increased. When the vessel is again shortened by the opposite movement a part of its contents is emptied centripetally. Circulation in the vena cava is thus considerably quickened, and the same is also the case with the hepatic veins. The other way in which movements assist the portal circulation is due to the fact that the liver, chiefly in movements forward and sideways in the lumbar region and in trunk-rolling, is pressed together and the blood partially pressed out of it in a manner which may be aptly compared to the squeezing of a sponge after it has been filled with water.

It is obvious that suitable movements have a considerable influence upon the whole portal circulation, and they form also a very important part of the "bedroom gymnastics" which many people take on getting up and going to bed, especially those leading sedentary lives, who have themselves often noted a markedly beneficial result on the functions of the liver, especially on the secretion of bile, which is easily observed.

* And between the strongest hypochondriac imaginations and the purest simulation there is every possible transition stage.

Direct massage of the liver has been little used, and it is doubtful whether it has any great future before it. The chief clinical literary work on this subject has been brought out by Dr. Gustave de Frumerie.*

He has massaged the liver over the small part of it accessible under the costal margin, with effleurage in the form of strokings from left to right and from right to left. A sort of petrissage, which Frumerie calls "ecrasement," is performed with the last phalanges of the left hand against the right lobe, and with the last phalanges of the right hand against the left lobe under the border of the ribs, by means of which the . hands, especially in deep inspiration, move towards each other. Another kind of petrissage, which is only possible with lax, thin abdominal walls, is performed by the masseur with four fingers, the hand, well supinated, pressing into the abdominal wall as far as possible against the under surface of the liver, the thumbs resting against the border of the liver immediately under the costal margin, while the patient lies in bed with head bent forward and legs flexed and abducted. Petrissage is then performed by pressing in towards the under surface of the liver, but only in few cases can it be done in this way. Pressure may be similarly applied to the gall-bladder with the fingers immediately outside the external border of the right rectus abdominis where it meets the margin of the ribs. When this is possible petrissage is performed with the patient sitting in forward-leaning position (with abducted legs). In this position one can also perform vibrations on the liver.

Frumerie uses all manipulations in the order thay have now been described, or similar ones, in hypertrophy of the liver, in cirrhosis of liver, especially in the (very rare) hypertrophic form; in some forms of diabetes, when the formation of sugar may be supposed to arise, not by increased activity of the liver cells, that is to say by increased metabolism, but by diminished activity of the cells so that they do not store enough sugar as glycogen but allow too much of it to pass into the hepatic veins +; in gout, which is thought by many to be due to disturbances of the liver; in catarrhal jaundice after the acute stage, and in diminished functional activity of the liver; in cholelithiasis after the crisis.

Frumerie gives cancer, abscesses or tumours in the liver, fatty and amyloid degeneration, as contra-indications to liver massage.

With lack of experience I have no right to deny the value of liver massage, and I acknowledge most willingly Dr. Frumerie's service in testing it and discussing its uses.

Personally I have so little faith in the therapeutic value of liver massage that, in spite of having treated in Carlsbad every year a considerable number of cases of this kind, I have no desire to use it in hypertrophic cirrhosis, in which it might be supposed to be of most value.

* "Le Massage direct du foie et des voies biliaires," by Dr. Gustave de Frumerie: Paris, 1901.

+ This probably occurs in the so-called alimentary glycosuria with small secretion of sugar an hour after a meal, which form may be called, with Gilbert, diabete par anhepatie.

The Spleen may be affected by movements in the lumbar region, by means of which part of its blood is pressed out. Whether any attempt has been made to affect it by massage, which one might suppose to be of use in the enlargement of the organ after malaria, I do not know.