The Effect of Massage on the Number and 
Haemoglobin Value of the Red 
Blood-Cells. 
BY 
JOHN K. MITCHELL, M.D., 
OF PHILADELPHIA. 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
FROM 
May, 1894. Extracted from The American Journal of the Medical Sciences, May, 1894. 
THE EFFECT OF MASSAGE ON THE NUMBER AND HAEMO- 
GLOBIN VALUE OF THE RED BLOOD-CELLS. 
John K. Mitchell, M.D., 
OF PHILADELPHIA. 
During several years past, "while using massage a great deal in vari- 
ous diseases, I have often wished to find some additional way of account- 
ing for the rapid improvement of color and nutrition which is seen under 
its application in patients ansemic from various causes, rather than the 
usual vague suggestion of hastened circulation and accelerated tissue 
change. 
In pursuit of this object, in the autumn of 1893 I made some ex- 
aminations of the blood of patients before and after massage. The first 
results were so astonishing that I reported them briefly to the College of 
Physicians of Philadelphia, in December last, and proceeded to a wider 
and more systematic study. The sum of the conclusions drawn from 
this extended observation is here presented. 
After this investigation was begun I found a paper by Professor 
Winternitz,1 which had previously escaped my notice, on the change in the 
number of red and white blood-corpuscles under hydrotherapeutic pro- 
cedures. The article was interesting and suggestive, but did not take 
up the detailed examination of blood before and after massage. 
In a “ Preliminary Note ” in the Medical News of December 23d, a 
brief account was given of a few of these studies upon the effect of 
massage as evidenced in the blood. The facts are so remarkable, the 
clinical conclusions which may be drawn from them of such widespread 
use and value, and the deductions which at once suggest themselves so 
revolutionary, so subversive of established views both in diagnosis and 
therapeusis, that the work has necessarily extended itself far beyond the 
limits originally proposed. I shall endeavor here to summarize the 
experiments made, to indicate the more important information acquired 
from them, the far-reaching possibilities which are hinted at in some of 
them, and the questions in the physiology and pathology of the blood 
which they suggest. 
The cases were thirty-five in number; several of them were examined 
a number of times, but, in order to exclude as far as possible the element 
1 “ Neue Untersuchungen ti. Blutveranderungen nach thermischen Eingriffen. ” Centralblatt 
f. inn. Medicin, 1893, No. 49. 2 
MITCHELL: MASSAGE AND THE BLOOD. 
of different individual susceptibility to the treatment, few were used 
more than twice. The diseases from which they were suffering included 
every variety of disorder affecting the integrity of the blood, except the 
severe acute fevers and malignant infections : simple ansemia, both slight 
and severe, chlorosis, anaemia from hemorrhage, from several toxic 
causes, from senile and other malnutritions, and at least one case in 
which the diagnosis of pernicious anaemia had been made by competent 
observers. This diagnosis was partially verified by the death of the 
patient without other symptoms than those of progressive anaemia,1 
although no post-mortem examination was obtained. Another case of 
very extreme anaemia, at first thought to be of pernicious nature, is still 
under observation, and at present much improved. A number of trials 
were also made on persons in whom there was no evident anaemia, and 
several on individuals in perfect health. 
As will be seen from the examination of the tables, the results were 
uniformly upon the side of increase, except in three cases. The increase 
in some was very small, but the tendency seems always to have been in 
that direction. In two of the three persons whose count was lessened 
after massage, active exercise had been taken just previous to the count. 
One had walked about two miles and a half before the examination, 
upon a very cold day, in the teeth of the wind; the other had walked 
half a mile to a country station, come ten miles in the train, and then 
walked half a mile in town again immediately preceding the examina- 
tion. In both of these there was marked diminution of the number of 
red globules after the application of massage, but these cases cannot be 
considered as contradictory of the results obtained in disease. They had 
already a greatly increased activity of circulation, and the rest as well 
as the rubbing had a share in the reduction. The third (Case YIL), 
by a nurse’s mistake received his dinner after the completion of his 
massage and before the count was begun, which may have interfered 
with the full and usual effects of the manipulation. Previous and sub- 
sequent estimations gave decided increase. 
It should be added that great care was used in ascertaining the rela- 
tion to meals of the hour of examination, as it is well recognized that 
the corpuscles are increased during the active process of digestion, and, 
where the time was near a meal, the fact is mentioned in the tables. 
Any efficient variety of the several types of manipulation which go 
under the common name of massage would produce similar if not 
equally marked results. In some of the cases where I did not person- 
ally oversee or direct the massage, half an hour was thought by the 
attendant a sufficiently prolonged application. The counts of these 
1 Dr. John H. Musser, in whose care this patient was, states that he would prefer to make a 
diagnosis of “ severe ansemia from atrophy of the gastric mucous membrane,” as the reduc- 
tion of the corpuscular elements was not very great. MITCHELL: MASSAGE AND THE BLOOD. 
3 
patients showed such small changes that inquiry was made, and after- 
ward in the same cases a longer rubbing was used, with much more 
decided increase. If general massage is to be of service, it will be found 
that a full hour must be given to it. 
A large proportion of the cases were examined by myself. The rest 
were divided among several observers, in order to eliminate as far as 
might be the element of personal error. lam especially indebted to 
the assistance of Dr. C. W. Burr and Dr. F. S. Pearce. The kindness 
of Dr. John H. Musser, Physician to the Presbyterian Hospital, allowed 
Dr. Pearce to examine a number of patients under Dr. Musser’s care 
in that institution, including one in whom “ pernicious ansemia ” would 
seem a permissible diagnosis, and another (Case XXII.) which might, 
if judged by the blood, have been similarly classed, although there were 
also present severe spinal (ataxic) and hysterical symptoms, reversed and 
contracted color-fields, hemi-ansesthesia, etc. Several cases were counted 
at various times by all three of us, and Case XX. had the advantage of 
an examination by Dr. Frederick P. Henry, whose great experience in 
the study of the blood makes his confirmation of the results very valu- 
able. lam indebted for the notes of the cases of malarial fever (Cases 
XXIX. and XXX.) to the politeness of Dr. John S. Billings, Jr., Resi- 
dent Physician of the Johns Hopkins Hospital. 
The instruments used were the Thoma-Zeiss hsemocytometer and 
Fleischl’s hiemoglobinometer in all cases except two or three of my own, 
where the counts were made with the Malassez “ compte-globule ; ” the 
estimates made side by side with the Malassez and Zeiss instruments were 
generally in remarkably close accord. 
The accompanying tables explain themselves for the most part. In the 
first columns the “cases” and “observations” are numbered separately 
for convenience of reference, the age and sex are given, and a brief 
diagnosis; then follow the state of the red and white corpuscles and the 
haemoglobin value before massage, and in the same order in the last 
three columns are presented the results of examination following mas- 
sage. The manipulation was, except where otherwise noted, a full hour 
of thorough, deep general massage. 
Perhaps one of the most striking results of an examination of the 
above figures is the large number of cases in which the count before 
massage far exceeded the ordinary normal standard of the text-books in 
the number of corpuscles in a cubic millimetre. Apparently a good 
many of the cases had some degree of plethora. Seventeen persons 
presented more than five and a half million of .corpuscles, and of this 
number six had more than six and a half million. Yet, except two 
perfectly healthy individuals, there was scarcely one of these who would 
not have been at once described as “ ansemic ” if judged by the external 
appearance alone. It is, of course, to be said that some of them, like 4 
MITCHELL : MASSAGE AMD THE BLOOD. 
Case. 
Obser- 
vation 
Age. 
Sex. 
Disease. 
Before massage. 
After massage. 
Bemarks. 
Bed 
blood-cor- 
puscles. 
White 
blood- 
corpusc. 
Hserao- 
globin- 
value. 
Bed 
blood-cor- 
puscles. 
White 
blood- 
corpusc. 
Haemo- 
globin - 
value. 
I. 
1 
25 
M. 
Healthy 
5,675,000 
110 
7,950,000 
120 
Hospital interne. 
2 
Same subject . . . 
5,650,000 
110 
8,125,000 
120 
II. 
3 
26 
M. 
Healthy | 
6.650.000 
6.800.000 
} 
110 
5,150,000 
110 
Count made after a sharp walk on a cold day. 
III. 
4 
25 
F. 
Subacute rheumatism 
7,100,000 
15,000 
80 
8,012,500 
25,000 
80 
Negro servant. 
IV. 
5 
43 
F. 
Sciatic neuritis..... 
6,800,000 
85 
7,000,000 
85 
Physician ; rest treatment for sciatica. 
V. 
6 
45 
F. 
Hemiplegia (attack 18 days previous) 
5,925,000 
64' 
6,640,000 
70' 
Half-hour’s massage. 
7 
Same subject 
5,580,000 
62' 
8,133,333 
70' 
One hour’s massage. 
8 
“ “ 
4,600,000 
74' 
6,220,000 
78' 
See also Obs. 50-57. 
9 
tt tt 
5,425,000 
5,600,000 
10 
it it 
5,012,500 
12,500 
65 
6,675,000 
12,500 
75 
11 
ti u 
5,187.500 
65 
8,800,000 
70 
VI. 
12 
38 
F. 
Neurasthenia, chronic gastritis 
4,660,000 
5,866,660 
VII, 
13 
53 
M. 
Hemiplegia (attack 10 weeks prev.) 
5,050,250 
70 
6,725.000 
75 
14 
Same subject . . ... 
6,122,500 
65 
7.240,000 
07 
15 
“ “ 
5,000,000 
12,500 
70 
4,540,000 
12,500 
70 
By a nurse’s mistake received dinner after mas- 
sage and before last count was made. 
VIII. 
16 
16 
M. 
Transverse myelitis (recovering) 
6,900,000 
90 
8,100,000 
100 
Several months in hospital under massage and 
good diet. 
IX. 
17 
22 
M. 
Locomotor ataxia (doubtful) . 
6,575,000 
110 
7,340,000 
110 
Same as above. 
X. 
18 
16 
M. 
Anterior poliomyelitis (improving) 
6,200,000 
110 
7,400,000 
110 
“ “ 
XI, 
19 
37 
F. 
Hysterical delusions, mild melan- 
5,400,000 
80 
5,460,000 
80 
Had been 4 weeks under rest, massage, and full 
cholia. 
feeding when examined. 
XII. 
20 
40 
F. 
Neurasthenia 
5,150,000 
75 
5,600,000 
75 
XIII. 
21 
F. 
5,150,000 
70 
5,500,000 
70 
Appearance highly anaemic; massage three 
quarters of an hour. 
XIV. 
22 
22 
F. 
Simple anaemia .... 
4,275,000 
70 
5,450,000 
70 
Four weeks’ rest, massage, and full feeding. 
XV. 
23 
33 
F. 
“ “ 
4,550,000 
60 
5,100,000 
60 
XVI. 
24 
30 
F. 
Hysterical torticollis 
5,900,000 
75 
6,750,000 
90 
Appearance highly anaemic. 
XVII. 
25 
25 
F. 
Neurasthenia, dysmenorrhoea . 
3,637,500 
55 
6,025,000 
60 
XVIII. 
26 
03 
M. 
Convalescent from epidemic influ- 
4,550,000 
70 
6,400,000 
85 
Temp, before, 992/5° F. 
enza. 
“ after, 994/5° 
massage 70 minutes. 
XIX. 
27 
18 
F. 
Hysteria, general symptoms . 
4,150,000 
90 
3,300,000 
100 
Had walked to railroad station and travelled ten 
miles to town immediately before count. 
Effect of Massage upon the Blood. 
1 Haemoglobin was estimated by Gowers’ instrument. MITCHELL: MASSAGE AND THE BLOOD. 
XX 
28 
40 
F. 
Severe anaemia, January 11, 1894 . 
January 13, 1894 . 
1,650,000 
1 
18 
. 
Before all treatment. 
29 
1,500,000 
1,250 
18 
1,650,000 
12,388 
30 
Blood showed, poikilocytosis, megaloblasts, 
30 
Jan. 24th, after one week’s massage 
microcytes, and on staining, nucleated rod 
3,800,000 
35 
5,400,000 
35 I 
corpuscles. 
31 
daily. 
Menstruation on January 14th. 
Jan. 31st, no massage for four days, 
5,550,000 
50 
j 
no medicine. 
32 
Feb. 1st, five days without treatment 
5,900,000 
60 
The increase at this time was so great from day 
33 
to day that no further counts were made. 
March 31st 
4,800,000 
50 
Patient was operated for hemorrhoids, losing 
34 
Severe anaemia, 8 years’ duration . 
Doubtful posterior sclerosis and 
high-grade anaemia. 
August 1, 1893 
September 1, “ . . 
some blood. No treatment for 12 days after. 
XXI. 
F. 
1,350,000 
581.000 
950.000 
85 
1,500,000 
90 
Counted on fifteenth day from operation. 
Duodenal ulcer was suspected from pain and 
XXI I. 
35 
50 
F. 
36 
October 18, “ 
1,628,000 
other symptoms; no bleeding. 
January 16, 1894 
934,664 
15 
Poikilo-, micro-, and megalocytosis. On account 
of the suspicion of ulcer massage of the abdo- 
37 
January 18, “ 
825,000 
12 
940,000 
12 
38 
64 
January 25, “ 
987,500 
22 
1,450,000 
27 
men was omitted. See also Obs. 62. 
XXIII 
39 
f. 
Pernicious anaemia or anaemia from 
atrophy of gastric mucous mem- 
brane. 
40 
December 1st 
2,250,000 
56 
Emaciated and cachetic; too feeble for full mas- 
“ 28th 
2,600,000 
4,666,666 
sage; rubbed thirty to thirty-five minutes. 
41 
“ 29th 
2,225,000 
2,775,000 
No white blood-corpuscles could be found. 
42 
52 
m. 
‘‘ 30th 
2,600,000 
3,200,000 
Patient died Dec. 31; no autopsy obtainable. 
Counted by different observers on three sucoes- 
XXIV, 
43 
Toxic anaemia, chron. lead-poisoning 
3,725,000 
30 
■ 
44 
3,900,000 
4,000,000 
30 
30 
sive days at same hour. 
Abdominal massage for twenty-five minutes. 
45 
4,500,000 
30 
4(3 
Toxic anaemia, chronic lead-poison- 
4,000,000 
30 
6,500,000 
30 
General massage one hour 
XXV. 
47 
26 
ivi. 
5,100,000 
100 
5,925,000 
100 
Effleurage (forty minutes) was the only form of 
48 
F. 
mg. 
massage used. 
XXVI. 
40 
Malarial poisoning, choreic spasm 
4,700,010 
78,333 
70 
7,100,000 
184,210 
70 
White blood-corpuscles 1 : 60 before. 
“ “ “ 1 ; 38 after. 
of facial muscles. 
XXVII. 
49 
60 
M. 
Malarial poisoning, chronic gastritis 
6,600,900 
80 
7,050,000 
80 
(V.) 
50 
56 
F. 
Hemiplegia; January 12, 1894 
5,975,000 
12,500 
65 
6,550,000 
12,500 
80 
At an interval of one hour after massage. 
51 
January 18, “ 
4,950,000 
65 
5,250,000 
...... 
70 
At interval of ten minutes after massage.. 
52 
8,912,000 
70 
One hour and ten minutes after massage. 
53 
5,002.500 
12,500 
65 
8,240,500 
76,000 
70 
One hour’s massage; first examination fifteen 
January 25, 1894, 3 p.m. 
“ 30, “ 3 p.m. 
minutes after massage. 
54 
7,297,500 
25,000 
78 
One hour and fifteen minutes after massage. 
55 
5,750,000 
67 
7,975,000 
70 
Immediately after one hour’s massage. 
56 
5.15 p.m. . 
8,845,000 
70 
One-half hour after. 
57 
.. 
6,875,000 
70 
Three hours and fifteen minutes after massage, 
i. e.,8 p.m.; supper at 6 o’clock. 
XXVIII. 
58 
Neurasthenia following dysentery, 
5,612,500 
69 
8.062.500 
5.512.500 
70 
Dinner one hour before treatment. 
1 
January 20th. 
1 
68 
Half-hour after massage. 
One and one-half hours after massage. MITCHELL: MASSAGE AND THE BLOOD. 
Obser- 
Before massage. 
After massage. 
Case. 
Age. 
Sex. 
Disease. 
Remarks. 
vation 
R. B. C. 
W.B.C. 
H. 
R. B. C. 
W.B C. 
H. 
XXIX. 
59 
M. 
Malarial fever for three months, 
tertian ; January 1st. 
January 2d 
2.988.000 
3.004.000 
4,500 
5,000 
42 
42 
3,104,000 
7,500 
1 
45 ( 
No organisms in blood at time of count; aortic 
insufficiency. 
XXX. 
60 
19 
M. 
Malarial fever, paroxysm 22 hours 
3,456,000 
4,000 
59 
3,680,000 
6,000 
64 
Had had previous attack Oct., 1893, of double 
Jan. 4th, temp. 105° F. Jan. 5th. 
tertian ; counted one hour after massage. 
Quinine, gr. lx., Jan. 5th and 6th, 
3,232,000 
3,500 
60 
3,392,000 
4.500 
60 
Many crescentic and ovoid organisms seen. 
temp. 101.5°. Jan. 6. 
Administration of 
Iron. 
Before administration of 
After administration of 
Case. 
Obser- 
Age. 
Sex. 
Disease. 
iron. 
iron. 
Remarks. 
vation 
R. B. 0. 
W.B.C. 
H. 
R. B. C. 
W.B.C. 
H. 
XXXI. 
61 
38 
F. 
Fat, anaemic, slight chronic gastritis 
4,950,000 
85 
6,800,000 
85 
Fat; mucous membranes very pallid; gr. 5 iron 
pyrophosphate every two hours; took gr. 120 
in four days, and PI 101. d. tr. ferri chloridi. 
(XXII.) 
62 
50 
F. 
See Obs. 35-38 
3.200,000 
60 
4,160,000 
70 
Patient gained greatly since last count; appear- 
ance much improved. Pyrophosphate gr. 95 
in two days 
XXXII. 
63 
20 
F. 
Epilepsy, minor .... 
4,300,000 
50 
4,600,000 
50 
Pyrophosphate gr. 60 in thirty-six hours; ap- 
XXXIII. 
pearance highly anaemic. 
04 
28 
F. 
“ major .... 
4,300,000 
65 
4,850,000 
70 
Pyrophosphate gr. 90 in two and a half days ; 
XXXIV. 
appearance extraordinarily anaemic. 
65 
24 
F. 
Neurasthenia, dysmenorrhoea . 
5,225,000 
85 
7,000,000 
90 
In 48 hours took pyrophosphate gr. 60 and pil. 
1 
Blaud. gr.36; appearance highly anaemic. 
Use 
of Faradism. 
Obser- 
Before use of faradism. 
After use of faradism. 
Case. 
Age. 
Sex. 
Disease. 
Remarks. 
vation 
R. B. C. 
W.B.C. 
II. 
R. B. C. 
W.B.C. 
II. 
XXXV. 
66 
59 
M. 
Hemiplegia—general senile degen- 
erative changes. 
6,215,000 
12,500 
6,200,000 
15,000 
Patient very weak. Slowly interrupted faradic 
current to all the muscles, occupying one 
67 
Same case 
5,300,000 
12,500 
75 
6,175,000 
15,000 
75 
hour. MITCHELL: MASSAGE AMD THE BLOOD. 
7 
Cases YIIL, IX., and X., were under full feeding and receiving every 
possible tonic treatment; still, one would not ordinarily suspect a patient 
with anterior poliomyelitis of long standing of having over six million 
corpuscles and over 110 per cent, of haemoglobin, especially one many 
weeks in a hospital. Still less would it generally be thought that a hospital 
resident physician would have such an excess of corpuscles and haemo- 
globin as obtained in Case I.; the effect of a year or two’s living in a 
hospital usually is to blanch them effectually. But all of these cases 
were examined more than once, and in all of them the excessive number 
of corpuscles was verified by the results of more than one observer. 
Cases VIII. and X. were both examined by Dr. Burr and by me at 
different times, with counts practically the same. 
The next most striking fact is that, while a very large increase of 
corpuscles was the rule, there was in only about half the cases a decided 
addition to the amount of haemoglobin after massage. In this respect 
the results differed very decidedly from those of Winternitz, who found 
an average increase of about 15 per cent, in the haemoglobin scale after 
his hydrotherapeutic applications. Twenty showed an increase of 5 
per cent, or over. A less difference than this cannot be accurately read 
on Fleischl’s instrument, and although changes of less amount are noted 
in the table, they are for that reason not included in this summary. 
The discussion of these facts may be postponed for the present. 
First, in examining the reason for this increase in the corpuscles, 
must be considered whether it is only a matter of alteration in the 
superficial circulation. It is hardly possible to dogmatically say it is 
not, since it cannot be proved, although some facts point very strongly 
that way. The superficial vessels are dilated by the stimulation of their 
muscles and nerves through massage, but the deeper ones are affected 
too, the alternate squeezing and relaxation by the hand-grasp acting 
like the heart-contraction to empty them and to encourage their rapid 
refilling. Nor would the supposition that the surface blood-currents are 
hastened serve to account for the steady, continuous, and well-main- 
tained improvement which is had in anaemia by the use of massage, nor 
to explain the large increase resulting from rubbing the abdomen alone, 
as in Case XXIV. (Obs. 45). Of course, it may be attributed in part 
to the indirect effect upon the quantity of blood in the peripheral chan- 
nels from the accelerated movement of the large amount of that fluid in 
the abdominal vessels. Yet, even if in anaemia the circulation in the 
peripheral vessels is insufficient, as the coldness of the extremities and 
the general surface pallor show, how does it come that the relative pro- 
portion of corpuscles in a given quantity of blood can be altered by mass- 
age ? If it be said that it is a sufficient explanation of the improvement 
which results from massage, that the increase is due to the fact that 
before manipulation the quantity of blood in these vessels was less than 8 
MITCHELL: MASSAGE AND THE BLOOD. 
it should be and that more was brought into them by the treatment, the 
increase of the number of corpuscles in a cubic millimetre would still be 
left unaccounted for. There would be more blood in the vessels—but 
would there be more cells in a given quantity of it? Somehow, glob- 
ules must have been called into circulation which were not previously 
in active movement through the body. If cells thus out of service can 
be induced to go upon their way through the vessels it certainly follows 
that an anaemia like that of Case XXVIII., and many others, is not, in 
the ordinary sense of the word, an anaemia at all. In Case XXVIII. 
before massage there were 4,500,000 corpuscles and 70 per cent, of 
haemoglobin; after massage, 6,400,000 corpuscles and 85 per cent, of 
haemoglobin. Corpuscles could not have been manufactured in that 
time to meet the demand created by an increased superficial circulation ; 
they must have been in reserve for emergencies, or lingering, as I said 
in my “ Preliminary Note,” in the byways of the circulation, and what 
appeared to be an anaemia was really but a lack of activity in the cor- 
puscles or in the circulating fluid generally. Some such explanation as 
that all the globules were not in use will answer for such an instance, 
where both the corpuscular elements and the haemoglobin were greatly 
increased by massage. But the same explanation will not do for the 
much larger number of examples where there was a decided increase in 
the number of corpuscles, without like addition to the percentage of 
haemoglobin. An hour’s massage can scarcely cause increased pro- 
duction, though after repeated treatment the making of blood-cells may 
be stimulated ; but the effect upon metabolic processes of increased 
activity and movement of the cells must, for the time at least, be much 
the same as though their number were actually as much greater as it 
seems to be. 
Where the corpuscles are increased and the haemoglobin remains as 
before, it is difficult to account for the lack of change in the amount of 
this substance. It may be that at any time there are a number of cor- 
puscles carrying but little haemoglobin, and that these are brought into 
action by the mechanical stimulation and general increase of the circu- 
lation. But before this happened where were they? The condition 
cannot be wholly due to disease, since it is present in healthy men (see 
Obs. 1 and 2). Did it arise only from adding to the number of red 
globules in the peripheral vessels at the expense of the rest of the circu- 
lation, the increase of haemoglobin would be directly proportional to the 
increase of globules , but this is rarely the case In Case 1., 10 per cent, 
represented the increased haemoglobin value, but the corpuscular addi- 
tion was almost 50 per cent, of the original amount, and nowhere have 
wre seen the haemoglobin rise more than 15 per cent. One conclusion 
must be that even in health there are vast numbers of corpuscles avail- MITCHELL: MASSAGE AND THE BLOOD. 
9 
able for use if called for. The deductions from this fact as to diseased 
conditions will be spoken of later. 
As was also said in the “ Preliminary Note” in the Medical News, it is 
not difficult to imagine some such explanation as possible when one 
recalls the appearance of the bloodvessels in living tissues under the 
microscope. “In the lesser capillaries there appears every now and 
then to be a clogging, and for a time the corpuscles scarcely move. 
When this state is overcome in one place, a like condition is evident in 
another little vessel. Even in the larger channels many corpuscles seem 
not to share in the general movement, and to be temporarily out of the 
current. The white ones especially cling along the walls, and some of 
the red ones progress less rapidly than others, or linger for an instant, 
as if they were in an eddy or a side current. A portion of the blood, 
therefore—and, when the whole capillary system is taken into account, 
it must be a large portion—is not at all times in active circulation.” 
What we can see under the microscope is what takes place in the 
tiniest branches of the extreme peripheral circulation. We can scarcely 
suppose that in the larger channels the same phenomenon is going on 
upon a more extended scale, for there the stronger movement of the 
current would forbid it. 
Hayem has said that the improvement which we desire to make in 
anaemia is an increase in the active and circulating amount of haemo- 
globin. Apparently this is exactly what we do get a small degree of by 
this method. 
Another thing very desirable to know is whether the corpuscles thus 
introduced into circulation are in all respects similar to the ones nor- 
mally found moving in the vessels. It has seemed to me in most of the 
cases that there has been no decided difference between the microscopic 
appearance of the corpuscles before and after massage. In a few 
instances, and more notably in those cases which were suffering from 
very high grades of anaemia, like Cases XX. and XXI., it appeared to 
me that the number of blood plaques was greater after massage; but 
the former case was one in which every symptom pointed to pernicious 
anaemia, and, while this diagnosis is very far as yet from being borne out 
by the result, yet the microscopic changes in the blood were all such as 
we are accustomed to find in cases of advanced progressive anaemia. 
There were numerous corpuscles very much increased in size; there 
were nucleated red corpuscles; there was poikilocytosis, and in several 
slides, Dr. F. P. Henry, who saw this patient in consultation with me, 
found upon staining a few nucleated red corpuscles. The white cor- 
puscles were enormously increased ; before massage they were only 
1:1200, but after massage this proportion was very greatly altered, 
becoming 1:134. This also was one of the cases in which a great MITCHELL; MASSAGE AND THE BLOOD. 
difference in the haemoglobin percentage was effected. The Fleischl 
instrument before massage gave us between 15 and 18 per cent., and 
after massage over 30 per cent. My friend Dr. Judson Daland, who 
upon another occasion examined this patient,1 tells me that the readings 
of the Fleischl haemoglobinometer below 20 are much too low, and he 
has suggested a very ingenious plan for overcoming this difficulty. This 
same case is perhaps the one which shows most valuably the amazing 
effects of massage alone. The count, as will be seen from the table 
(Obs. 28-32), was, upon the 11th and 12th of January, 1,500,000 red 
corpuscles and 15 to 18 per cent, of haemoglobin, while upon the 24th 
of January, the patient having in the interval had no other treatment 
than massage and rest in bed, without any excessive feeding, the count 
was 3,800,000 before and 5400,000 after manipulation. It is noticeable 
that in this examination the haemoglobin was the same both before and 
after treatment—between 30 and 35 per cent.—and was not materially 
increased over the percentage upon the previous occasion, when the 
count had been very much lower. All treatment having been stopped 
from the 24th of January, the patient receiving neither medicinal nor 
mechanical treatment of any kind, the corpuscles nevertheless went on 
increasing until, on January Blst, they had reached the amazing figure 
of 5,550,000, with 50 per cent, of haemoglobin. This examination was 
made by Dr. Burr, and the next day, February Ist, I made an estimate 
myself, with the result of finding 5,900,000 corpuscles and 60 per cent, 
of haemoglobin. 
It will be seen from the column headed “Diseases” in the table, 
where a brief statement of the patient’s condition is given, that almost 
every form of anaemia and malnutrition is included, and that in all but 
three of the observations there was an increase in the number of cor- 
puscles, varying from a very slight addition to over three and a half 
million. Nor does the increase seem to depend at all on the form of 
disease from which the patient was suffering. In the several healthy 
cases the increase was great, although the persons examined appeared 
to be already in a condition approaching plethora, judged by the counts 
alone. This was an entirely unexpected result. In slighter anaemias 
the improvement was very marked (Cases XIV. and XV.). In mala- 
rial anaemia, of which two decided cases are in the table (Cases XII, 
and XXVI.), there were like changes. In forms due to malnutrition 
(Cases XVI., XXXI., XXXII., and XXXIII.); in severe simple 
anaemia (Case XXI.); in senile degenerative changes (Cases V. and 
VII.); in the case of extreme ansemia from atrophy of the gastric 
1 Dr. Daland made a single estimate with the hasmatokrit, giving as a result 2,500,000 red 
cells. The white cells could not be properly rated owing to the presence of large numbers of 
microcytes, which altered the white column unduly. At the same time I made observation 
No. 30, which, if accurate, would show a much larger number of red globules. MITCHELL: MASSAGE AND THE BLOOD. 
11 
mucous membrane (Case XXIII.), and in the cases of metallic poison- 
ing, which were of the most chronic description (Cases XXIY. and 
XXV.), varying degrees of increase resulted. 
It was not always possible to make several successive examinations at 
short intervals of the same patient, as the time over which this would 
have spread the examinations would have introduced other factors, such 
as an unusually prolonged abstinence from food on the part of the 
patient; but, in some of the cases that were counted at intervals after 
rubbing, the increase was found in one hour or more to be greater than 
in a few minutes after the completion of manipulation (Obs. 53-58). 
Hsemoglobin is occasionally increased by massage, but by no means 
uniformly; it appears to be rather the exception than the rule to find 
large addition to the percentage of coloring matter. It occurred in 
twenty cases (omitting increases of less than 5 per cent., which are 
untrustworthy); but in one or two of the more severe cases (Cases 
XVI., XVIII., XX., and XXII.) it was very marked. The source of 
supply of hsemoglobin for the red corpuscles is a matter still in doubt. 
Judging from the frequency with which a great reduction of hsemoglobin 
is seen in ansemias, while the corpuscular count remains near the normal 
(chlorotic type), the cells in all cases of poverty of blood vary less than 
the hsemoglobin ; they may be inaccessible to our observation; they 
may themselves be affected by this reduction in their hsemoglobin value, 
so as to make them less active, and again it may be that the hsemoglobin- 
production cannot be so rapidly or readily increased as the manufacture 
of corpuscles. 
With the exception of the one patient who died during the study of 
the blood, by far the worst case, judged by appearance, general symp- 
toms, length of continuance of the disease, and by blood examination, 
was Case XX. By an accident she was given iron for a few days, 
which may somewhat have interfered with the result; but other than 
this she had no more treatment than rest in bed, without excessive 
feeding, and very thorough-going daily massage; yet, with this, as I 
have said before, the hsemoglobin and corpuscular elements both in- 
creased with amazing rapidity and continued to increase even when all 
treatment was stopped, a result which sufficiently does away with any 
idea that the improvement in these cases is due to a temporary effect 
upon the superficial circulation. Here again was to be seen a dispro- 
portionate improvement in hsemoglobin and corpuscles, for when the 
corpuscles had reached nearly six millions, the hsemoglobin had only 
attained to 60 per cent. 
No doubt there is another factor in these causes of improvement; the 
better tone of the muscles, of the heart, and of the general circulation, 
which is so quickly shown in such patients. Case XX. had mitral 
valvular disease and a consequent murmur, as well as a very loud and 12 
MITCHELL: MASSAGE AND THE BLOOD. 
clear haemic murmur, and suffered from a general deficiency of the cir- 
culation, manifesting itself in a tendency to chilliness and coldness of 
the extremities. The very first hour’s massage left her warm and com- 
fortable, and its effect was felt for several hours and continued from 
day to day to last during a longer period each time. The organic 
murmur was little changed, but the hsemic murmur, which, if altered 
at all during the first week, was somewhat louder, has constantly lessened 
in intensity till now it is a very faint, soft bruit. 
A few words must be said about the results of the administration of 
iron in large doses during a very short time. The experiments (five) 
were too few to he conclusive, but in all there was marked increase of 
the corpuscles, although the hsemoglobin made no perceptible gain. 
The pyrophosphate was used because of its solubility and unirritating 
quality. The ease with which such large quantities of iron were borne 
by patients with the irritable digestion of ansemia wras remarkable. 
Probably, had the drug been longer continued the haemoglobin would 
have shown more effect of it. But this and other questions relative to 
the effects of medicine upon the cellular production must be reserved 
for further study. In one case (Case XXXV.), an unfavorable subject, 
a trial was made of the effect of slow faradic interruptions applied to 
the muscles, but the result is uncertain and the case is only added for 
its evidence of another means of tonic treatment. 
To sum up, first, the certain results: In health, massage increases 
the number of red corpuscles, and to a less degree and not so constantly 
their hsemoglobin value. 
In all forms and grades of ansemia there is a very constant large 
increase in the number of red corpuscles after massage; this is greatest 
at an interval of about an hour, after which it slowly decreases. This 
decrease is postponed more and more if the manipulation be daily 
repeated. An improvement also takes place in the general tone of the 
circulatory and muscular systems. 
There is an occasional but inconstant increase in the haemoglobin 
value, and this increase is proportionately less great than that of the 
cellular elements. 
It has been doubted if so powerful and fatiguing a method of treat- 
ment as massage is safe or desirable in very high grade anaemias. It 
is now for the first time made clear that it is of great and certain service 
and without danger in such cases, no matter how feeble. 
It is evident, too, that our present definitions of anaemia are insuffi- 
cient. An essential part of the description in all of them is that there 
are defects of number, of color, or of both in the blood. This is not 
necessarily or always true. The fault may lie in a lack of activity or 
of availability in the corpuscles. The state of things in the system may 
be, to draw an analogy from economic conditions, like the want of cir- 13 
MITCHELL: MASSAGE AND THE BLOOD. 
culating money daring times of panic, when gold is hoarded and not 
made use of, and interference with commerce and manufactures results. 
Lastly, neither an ansemic appearance nor a blood count is alone 
enough for a certain diagnosis. Other signs must be used as a check on 
the blood examination for the establishment of the existence of ansemia. 
For instance, many cases here recorded had full normal or even supra- 
normal corpuscle-count, with a good percentage of haemoglobin. Yet 
they presented every external sign of poverty of blood: pallor of skin 
and, more important still, of mucous membranes, cold extremities, anor- 
exia, indigestion, dyspnoea on trifling exertion. In such cases we must 
suppose either that the total volume of the blood is reduced, or that the 
usefulness of the corpuscles is in some way impaired, or that both these 
troubles exist together. 
The white corpuscles have not received sufficient attention in this 
study, although it seems as if in most cases they were increased as well 
as the reds. 
Next, as to general conclusions : It is possible that even in health there 
may be a certain varying percentage of corpuscles out of the moving 
current of the blood. If so, where are they, and what are they doing ? 
We know by direct observation that all corpuscles do not travel with the 
same rapidity, that some loiter and delay. Our studies prove clearly 
enough that a great number of cells may be brought rapidly into the 
circulation by massage, and it seems at least probable, as Dr. Pearce 
has suggested to me, that those thus thrown into the current have less 
haemoglobin value than the ones already in movement. This is a 
possible inference from the fact that corpuscular increase does not imply 
an addition of haemoglobin, or at least not a proportionate addition. 
Have some of the globules thus cast into the hurrying stream of the 
blood been delaying to take up or unload their freights of coloring matter 
or oxygen ? Do corpuscles in states of disease behave differently toward 
haemoglobin, so that they absorb it less well, or transport it less success- 
fully, or give it up with abnormal readiness ? Some forms of anaemia 
may be due to an increased delay on the part of such cells as these, 
lingering sluggishly about their business, and only pushed and forced 
into greater activity and usefulness by the direct stimulus of massage. 
Whether these globules are immature ones or ones that have been made 
use of to the extent of their capacity also remains to be discovered. 
Even when direct anaemia has been caused by hemorrhage, a part of 
the result may be due to the inactivity of a certain number of the cor- 
puscles, and we may find in massage a valuable aid in the treatment of 
such cases, both by the impetus it will give to cells indisposed or dis- 
abled for free movement, and by stimulation of the making of corpus- 
cles, I hope soon to publish some facts as to the application of manipu- 
lation to such disorders. 14 
MITCHELL: MASSAGE AND THE BLOOD. 
The excess in amount of blood brought into the circulation by massage 
may be one of the reasons why in occasional sensitive patients we see 
such discomforts as headaches follow its use. Practically, we have added 
a certain number of millions of cells to their tissues, and need not be 
astonished if some signs of plethora result. 
It is evident that massage has complex effects and that the numerical 
increase of the corpuscles, the added hsemoglobin value, and the better 
circulatory and muscular tone, may be due to many causes operating 
together—a vasomotor nerve stimulation, a direct hastening of the 
venous currents, an indirect hastening of arterial flow, an improved 
metabolism, are only some of them. t Johrrjal 
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