When applying massage to cases of rickets the treatment should be general. Even if there is no apparent deformity of the limbs, these call for treatment so as to ensure their fullest possible nutrition, and to assist in elimination of waste products. Abdominal massage is called for to relieve any tendency to constipation that may exist, and to assist the portal circulation.

The primary anaemias are not calculated to derive any great benefit from massage treatment, beyond the fact that it is always possible to add greatly to the patient's sense of well-being by its employment.

In dealing with secondary anaemias, however, much benefit may be derived from skilful massage. Graham has epitomised some elaborate investigations by J. K. Mitchell as to the effect of massage on the blood. After treatment there is usually a great increase in the number of red corpuscles, and frequently in haemoglobin. Moreover, the effect is not transient, as, when the improvement had been noted throughout a course of massage, its cessation did not lead to any return of anaemia. He adds that massage does not create blood-cells, and indicates the manner in which benefit may accrue by quoting from Mitchell, who likened anaemia to "the want of circulating money in times of panic, when gold is hoarded and not made use of, and interference with commerce and manufacturing results."

In all cases of illness it is a little difficult to decide the relationship of cause and effect. In chlorosis there is almost invariably associated a marked degree of constipation. The latter may be the cause of the anaemia; and certainly it is wise, from the massage point of view, to consider all anaemia cases, that we are called upon to treat, as being toxic in origin. Abdominal massage, to aid the portal circulation and to combat the constipation, should therefore be awarded a prominent place in treatment. Breathing exercises should always be prescribed.

Some physicians request the masseur to try to reduce oedema of the legs in patients suffering from chronic nephritis. It is a hard and often a heart-breaking task, were it not that the patient derives great comfort from proper manipulation. Nothing need be added as regards the local treatment to what has already been said on the treatment of oedema (see p. 18). This is applied for relief of the symptoms and will not assist recovery in any way. Part of the main trouble is probably toxic, and it is well known that general (and particularly abdominal) massage can greatly increase the output of urine, and can also add materially to the percentage of solids excreted in it. The patient with oedematous feet is deprived of exercise, and so the accumulation of waste products proceeds apace. This added toxicity of the blood can only act detrimentally upon the already diseased kidneys. Thus permission to perform abdominal massage should always be sought when called upon to treat a chronic nephritic; but, if it is granted, one danger must be borne in mind. Nearly all these cases have a high blood-pressure, and every care must be taken to avoid causing an excessive or a sudden rise. Otherwise the patient may run the risk of cerebral haemorrhage.

Abdominal treatment must therefore be of short duration and gentle in character, and should aim chiefly at assisting the portal circulation. There is rarely any need to give treatment for constipation, as this is invariably attended to with care by the medical man as a routine part of treatment.

Though not strictly speaking a general constitutional disease, this is probably the most suitable place to refer to the treatment of Grave's disease (exophthalmic goitre). From the purely massage point of view we should consider the patient as a victim of neurasthenia combined with a general toxaemia. It is wise to treat all these patients on the lines advocated for the treatment of neurasthenia, with this difference, that general abdominal massage, designed particularly to assist the portal circulation, should always find a prominent place. Treatment should therefore begin with surface stroking of the legs, general abdominal massage follows, and finally the back, arms, and head regions receive their dose of sedative treatment in the order named. There may be a temptation to administer local heart treatment. It is probably unwise from the psychological point of view. The patient suffers from tachycardia, and often imagines that the heart is seriously diseased. The physician may have to devote much time to dispelling this dread, and to administer local treatment may well lead to the supposition that his assurances are mere soporifics.

One word of warning is required about massage of the neck in this condition. It must be conscientiously avoided. No pressure whatever must be placed on the gland, as this leads to increased absorption. This is recognised in the operating theatre, where it is well known that the danger to the patient is almost directly proportionate to the extent of manipulation of the gland. It was probably owing to lack of realisation of this fact that so many patients lost their lives in the earlier days of operation for this complaint.