A considerable number of diseases and abdominal conditions contra-indicate or limit the use of massage when it would be otherwise indicated. There may be contra-indications to all massage, or more often to massage of an affected area.

In the first place, for massage the skin must be fairly normal, and therefore it cannot be given in several skin conditions. Unhealed recent injuries or burns, erysipelas, syphilitic skin affections of different kinds, certain forms of eczema, herpes, pemphigus, acne, boils and carbuncles, phlegmonous processes, lymphangitis, and gangrene preclude the possibility of massage within their area. Any of the above which are of an infectious and purulent nature especially contra-indicate massage in their area, since it would help to spread the infectious elements and pus and so increase the destruction of the tissues.* In many cases some manipulations may be used while others would be quite unsuitable. One can, for example, work upon an extensive scar by small deep frictions, in which that part of the scar lying under the finger tips accompanies them in their small excursions, even if it is firmly adherent to the underlying tissues. But it does not answer to apply strong effleurage, which would break the skin and cause ulcers. Deep effleurage is the manipulation which would be first excluded by anomalies in the skin, and can scarcely be used in such conditions as oedema, certain erythemata, urticaria-like wheals, small or linear ulcers, and in the pure anomalies of secretion.

Some diseases and changes in the blood-vessels contra-indicate massage in their area; others call for great caution in its use. Aneurysms might easily be broken by manipulation, and embolism follow. Advanced atheroma forbids local manipulations, which might cause detachment of particles from the inner wall of an artery and otherwise cause injury. Marked varicosity of veins, with or without phleboliths, for similar and obvious reasons does not allow any of the stronger manipulations in the immediate neighbourhood. (On the other hand, cautious efflcuragc may be of use in many cases of chronic phlebitis and periphlebitis, with their accompanying evils; of which more anon.) Acute phlebitis and periphlebitis absolutely contra-indicate all massage in their area, since it could only provoke extension of inflammation and lead to danger of embolism from the thrombosis which frequently accompanies these troubles. Lymphangitis, which always depends on septic influences, likewise constitutes a "noli me tangere" for the masseur. Fresh and incompletely organised thrombi contra-indicate massage in and near their area on account of the danger of embolism. It is best to allow from two and a half to three months after the formation of the thrombus, so that organisation is sufficiently advanced for the thrombus to be fixed, before treatment by massage is begun.* Lastly, we must mention as contra-indications some rare diseases in which the blood vessels undergo changes not fully understood whereby severe bleeding may arise after quite mild and, in ordinary circumstances, harmless manipulations - haemophilia, Werlhofs morbus maculosus, scurvy, certain cases of purpura, and leukaemia. Apart from these affections, occasionally, especially in elderly people, one meets with such a susceptibility to mechanical effects on the blood vessel walls that manipulations must be performed with very moderate strength.

* After acne, boil, carbuncle, erysipelas, and other processes have run their course, leaving behind inflammatory products and thickenings in the skin, massage may be used to get rid of these (see below).

Purulent processes of all kinds contra-indicate all massage in their area. This could only increase the danger of the pus spreading more widely among the tissues, with consequent rapid destruction. I know of only one exception to this contra-indication. Dentists are accustomed to order gouty, diabetic, and other patients suffering from alveolar pyorrhoea to massage their gums, with good result.

* In the beginning of my medical practice I had a painful experience of the necessity not to wage war too early against this contra-indication. The case was that of a shopkeeper about forty years of age who broke his femur at the junction of the middle and lower thirds; there was great formation of callus, and a thrombus due to compression formed in the femoral vein. Over five weeks had passed since the thrombus first appeared, the collateral circulation was slowly becoming established, the whole limb was much swollen with a hard oedema, the knee joint was quite stiff, movements of the ankle joint were limited, formation of connective tissue, marked atrophy of muscles, and severe and prolonged loss of function were to be feared for the future. Before treatment was begun I pointed out to the patients doctor, an experienced surgeon, the danger of embolus, but he pointed out the comparatively safe age of the thrombus and the dangers of further postponing massage treatment. I began, therefore, with great caution, avoiding the area of the thrombus, and for a week all went well. Then, to my great alarm, several hours after a massage seance, the patient had a sudden pain, with shivering and fever. Immediately afterwards I found over the lower and posterior portion of the right lung a definite circumscribed dulness. I gave up massage and treated the patient for his lung condition, from which he speedily recovered, whereupon, after consultation with my colleague, treatment by massage was resumed, greatly to the benefit of the patient. I have since always waited much longer before beginning massage in such cases. It was not a particularly pleasant case for me, and I relate it as a warning to others. I got off fairly easily, but others have been unfortunate enough to cause the death of the patient by massage in the neighbourhood of a thrombus.

In malignant tumours massage over the part increases the danger of metastasis.

In (tuberculous and other) foci of infection massage in the neighbourhood may help to disseminate the poison.

Kappeler in 1890 stated that the danger is not great in the case of staphylococci.

The spread of the poison is also a danger in the case of toxic foci (snake-bites, stings of insects, etc.).

Foreign bodies, for obvious reasons, prevent massage in their neighbourhood.

Osteomyelitis and all cases of infective periostitis prevent all massage in their neighbourhood by their tenderness if for no other reason.

Severe general or local diseases, which necessitate complete rest for the patient, do not allow of massage; this is true, in the first place, of all febrile diseases.

In acute inflammation of the kidneys massage over a large area should be given only in exceptional cases. E. Ekgren in 1901 found the albumin in the urine increased, especially by massage of the lower extremities.

Certain neuroses, and especially several forms of psychosis, make all massage impossible on account of the patient's irritability and lack of self-control. In high degrees of neurasthenia, and in many debilitated conditions where there is increased sensitiveness to pain, any massage which produces pain must be either left off entirely or performed with special gentleness and consideration for the patient's sensitive condition.

Abdominal massage must be specially considered in this chapter, as many changes in the abdominal organs, besides those already mentioned, more or less strictly limit its use.

Pregnancy I consider a definite contra-indication to abdominal massage. It is certainly stated that cautious massage, even of the uterus itself, may be performed without shortening or otherwise unfavourably affecting pregnancy (Asp). For practical reasons, however, it seems best even during the early months to regard this as a contra-indication; during the later months it seems a great mistake not to do so.

Large ovarian cysts contra-indicate abdominal massage. In these cases not only is it less effective, but it may produce extreme irritation of the peritoneum, and so help to increase the usual adhesions and render operation more difficult. The possibility of sudden rupture of the cyst by incautious massage must also be thought of.

Acute inflammatory processes, either in the abdominal cavity or its immediate neighbourhood (peritonitis, appendicitis, salpingitis, perimetritis, liver abscess, etc.), prevent abdominal massage, which might easily cause extension of the inflammation.

Some conditions of the kidneys, ureters, and bladder may prevent abdominal massage. In certain cases of stone, for example, where there has been haemorrhage during the passage of concretions, in hydronephrosis, and similar cases, abdominal massage, for obvious reasons, is out of the question. Abdominal massage incautiously given in cases of stone in the bladder may cause (and has caused) dangerous bleeding. The same may occur with papillomafa of the bladder.

Movable kidney is no contra-indication to abdominal massage, but should be noticed and avoided. It is a very common condition, especially in multipara', and can easily be recognised by any one accustomed to give abdominal massage.

Gallstones call for caution in manipulation when massage is performed near the gall-bladder. During their passage, or when they have given rise to inflammation, they contra-indicate abdominal massage.

In the presence of echinococcus abdominal massage increases the danger of rupture of the cyst.

In acute catarrh, ulceration, and similar conditions of the alimentary canal, abdominal massage is obviously out of the question.

In gastric or duodenal ulcer abdominal massage is contra-indicated, in that the accompanying stimulation might hinder healing and possibly cause haemorrhage.

Strangulated hernia contra-indicates abdominal massage; hernia of all kinds calls for caution.

Abdominal massage raises blood pressure often to a marked degree. It is therefore contra-indicated in all conditions in which there is liability to haemorrhage by rupture of blood vessels. In cases of recent haemorrhage in the brain, lungs or alimentary canal, in cases of aneurysm, in advanced arteriosclerosis, abdominal massage is out of the question.

In recent fracture there is risk of moving the fragments in performing massage. Effleurage, which is recommended by some to produce absorption of exudation, must be performed centrally from the seat of fracture; in some cases it may be performed with great caution also over the seat of fracture. Recent unreduced dislocations contra-indicate massage over them, and I consider the proposal to massage in these cases (to make reduction easier) quite unwarranted. Such treatment could only cause unnecessary pain for the patient and make reduction more difficult, since it is always easier the earlier it is performed.