Friction is rubbing with pressure, generally performed over small areas, with the palmar surface of the last phalanx of the thumb or of the three middle fingers, but also may be performed in other ways, e.g., with the base of the hand or with the whole palm. Friction is used chiefly to hasten retrogressive changes in inflammatory products, infiltration’s and exudations, to press into the outlying lymphatics the disintegration products, and so to promote their absorption. The direction of this manipulation is therefore unimportant, but it is generally necessary to use firm pressure. This is generally possible, but not always. When friction is performed over the eye or over inflammatory products in the abdomen and pelvis, it is obvious that it must be performed with very moderate pressure.
Fig. 6 shows friction as it should be performed for rheumatic infiltrations of the neck in the upper part of trapezius or occipitalis. The masseur presses in on the affected parts, performing a small movement with the apposed tips of his three middle fingers.
Fig. 7 shows friction performed by the thumb on the knee-joint over an infiltration in its capsule, an affection called by Swedish doctors “capsulitis.”
Fig. 8 shows friction performed over the left supraorbital nerve for rheumatic interstitial neuritis. It is a small matter whether one prefers to use the palmar surface of the last phalanx of the thumb or of the three middle fingers.
Fig. 9 shows friction with the palmar surface of the last phalanx of the middle finger above and through theeyelid for opacities in the cornea. The fingers perform a small movement from side to side with as much pressure as may be given without risk.
Fig. 10 shows friction in a case of sciatica due to muscular inflammation, performed with the palmar surface of the last phalanges of the three middle fingers, over the gluteal muscles, which in these cases are often the seat of rheumatic infiltrations.
Fig. 11 shows friction performed with the base of the hand in a case similar to that shown in Fig. 10. It is a form of technique seldom seen but not objectionable.
Fig. 12 shows friction with the base of the hand over infiltrations in the back muscles. The remark in reference to Fig. 11 applies also to this.
Fig. 13 shows friction over rheumatic infiltrations in the back muscles given with the whole palmar surface of the hand, a method less often used but very useful in cases of widespread infiltrations.
It is obvious that since all massage manipulations vary in form and may be performed in different ways with the same effect, and since effleurage and friction in particular have to some extent the same object, in that they promote absorption, there must be various transition forms between the two. But generally speaking, effleurage is performed over a large surface of skin and less pressure is used than in friction.
|Pétrissage consists of rolling, kneading, and pinching. Its physiological effects resemble those of friction in that it promotes absorption of the products of inflammation, and those of tapôtement in that it is a form of muscle stimulus. These react to a pinch as to a blow by a local contraction and thickening.|
Fig. 14 shows pétrissage over the upper border of trapezius, which is a favourite situation for rheumatic muscle infiltrations. The masseur grasps the muscle between his thumbs behind and his fingers in front and lets his hands perform a series of pinching or wringing movements.
|Fig. 15 shows pétrissage of the forearm as it is usually given in general massage. The masseur holds one hand on the front, the other hand on the back of the forearm, and kneads the muscle masses by a movement of one hand against the other.|
Fig. 16 shows the same procedure on the upper arm. By their movements against each other the masseur’s one hand works on the flexors, his other on the extensor muscles.
|Fig. 17 and 18 show pétrissage of triceps on the upper arm. In Fig. 17 the masseur holds his thumb on one side, his fingers on the other side of the muscle mass; in Fig. 18 the manipulation is performed by means of pinchings between the four fingers and the base of the hand; the latter form is much more seldom used than the former. Altogether, pétrissage is a form of massage less often used than effleurage and friction. Used as in Figs. 14 and 17, the manipulation has a diagnostic as well as a therapeutic value, since one can in this way palpate and recognise muscle infiltrations.|
|Tapôtement (Figs. 19-22) consists of manipulations which aim essentially at mechanical stimulation of muscles or nerves; these manipulations are all characterised by their blow-like nature and are named as already mentioned, hacking, beating, shaking, vibration* [See footnote below]. We work upon the skeletal muscles by beating them all over with the closed fist, by hacking them at right angles to their long axis with the ulnar border of the hand (Fig. 20), or, especially in the case of small thin muscles, as the extensors of the forearm, flicking them with the dorsal surface of the fingers generally held slightly apart (Fig. 21). By shakings performed from side to side with one hand on each side of the patient’s abdomen we affect both the muscles of the alimentary canal and its nerve elements. By hackings or vibrations over the head or spine we can mechanically stimulate the cerebro-spinal centres within their bony covering. By chest clapping we stimulate the vagus and consequently produce slowing of the heart-beat and pulse. We affect nerve trunks by percussion or vibration along their course, and lastly, we can stimulate the nerve endings in the skin by different kings of tapôtement, e.g., by blows with the flat hand or with different instruments.|
Fig. 19 shows back hackings in standing position as performed by Swedish gymnasts; tapôtement given with the ulnar border of the masseur’s hands, the fingers being parted.
|Fig. 20 gives a picture of tapôtement of the back in general massage. The hands are slightly supinated and strike the back with part of their dorsal surface. The hands go up and down several times on each side of the spine. Tapôtement is often given also over the spine.|
Fig. 21 shows a method of performing tapôtement on the dorsal surface of the forearm. The masseur, with fingers held apart, flicks the thin extensors of the forearm with their dorsal surface.
|Fig. 22 shows a method occasionally used by giving vibrations without instrumental aid over the posterior nerves on each side of and quite close to the spine. The three middle fingers of the masseur’s left hand go down the left side of the patient’s spine, the three middle fingers of his right hand down the right side, giving a series of small quick blows. This manipulation requires much practice.|
Generally speaking, massage as a whole is performed best by hand, and no instruments exist or can ever be produced with which one can, even approximately, perform the various manipulations that go to a massage séance as well as by the hands.
But it cannot be denied that in some cases one may with advantage make use of instruments. Certain forms of tapôtement and especially vibrations are performed much more smoothly, quickly, and strongly by means of instruments than by hand.
A great number of cheap, efficacious and durable vibrators are now in the market – the “Veni-vici vibrator,” the “Auto-vibrator,” the “Medical vibrator,” etc. Of Zander’s well-known and ingenious apparatus most are concerned with gymnastics, but several with massage, and among the latter those which aim at vibrations are, beyond a doubt, those which best fulfil their aim.
Some masseurs use india-rubber balls provided with handles and long or short levers. An instrument for tapôtement looks like a thimble with such a ball at its point. At one time a “palate” was used, a round flat wooden slab on a lever with a handle, to stimulate the skin by repeated blows. At some of the Swedish seabathing places different kinds of seaweed, chiefly Fucaceœ are used for the same purpose.
Some masseurs make use in other forms of massage of small wooden wheels, straps, brushes, gloves, sponges; the latter or metal wheels are used at times to give electric treatment along with massage. Most doctors who give massage themselves make use of their hands only, except in the case of instruments for vibration.
The strength of the manipulation is, of course, a very important factor, and varies widely with the different therapeutic aims and the different morbid anatomy underlying the special case. For instance, if one is dealing with a fresh sprain, and massage has chiefly an antiphlogistic aim, one sets to work, especially in the beginning of the treatment, with quite light effleurage; if one has before on an extensive hard œdema with a plastic tendency, effleurage as well as friction is firm; if the question is to get rid of already partially organised exudations round a joint after a joint inflammation, one must use hard friction; again, if it is perityphlitic (“appendicitis”) or parametric exudation, one must exercise unceasing care, remembering the proximity of the peritoneum and the danger of a new inflammatory process, etc.; all matters which we shall deal with later more in detail, but which in individual cases must be left to the good sense of the masseur. With beginners the commonest fault is to be too hard-handed, but prefessional masseurs* [See footnote below] often tend, on the contrary, to be too superficial. I would especially call attention to the erroneous statement of certain authors that massage should never be done hard enough to produce marks of discoloration of the skin, and that every such mark is the “fault” of the masseur. This may be true of general massage and some other cases, but very many of the cases for which massage is suitable (e.g., many chronic joint affections) need such strong massage that marks are necessarily caused. They are of little or no importance and soon disappear.
The length of the massage séance is also important, but there can be no general rule. Several points must be considered in deciding what is enough, and, in the first place, the nature of the lesion. Often in this, as in the strength of the manipulation, one must be guided by the patient’s general condition, since nervous, sensitive patients can stand neither a long séance nor hard massage. In these cases one must begin the treatment gently and with a short séance, gradually increasing the strength of the massage and its duration. For local massage generally a quarter of an hour is suitable. General massage (which is usually done by some one other than a doctor) takes at least half an hour, often more.
In certain acute cases, and especially when used as an antiphlogistic (by means of effleurage), as, for example, in a recent sprain of the ankle, massage should be performed several times a day; in other cases at least twice, never less than once a day.
The masseur should from the beginning accustom himself to use both hands and divide the work equally between them. While he is still new to the work, like other mechanical workers, he squanders his strength and becomes easily tired, but he quickly learns to obtain the greatest possible effect, and can do much more work than seemed at first possible.
The masseur should never make use of narcotics to prevent or remove pain which he must occasionally cause. The pain is seldom great, and there are other means of counteracting it. Latterly hypnotism and hypnotic suggestion have begun to play a part, in many cases with wonderful success; but I can offer no opinion on the subject, as I have never attempted it.
Massage is almost always given directly on the skin, since in giving it over clothing, as is done by some masseurs in certain cases, one loses technical accuracy. Regard for modesty in a doctor’s consulting room can be carried too far, to the detriment of more important considerations, and also to the extent of producing the painful self-consciousness it aims at avoiding. One takes care, especially with women patients, not to uncover more than need be uncovered, and not to uncover at one time more than the part about to be massaged.
Most masseurs make use of some lubricant to make the patient’s skin soft and smooth. This is often a necessity, especially for firm effleurage, as otherwise one cases pain by dragging the hairs of the skin, and may irritate the glands of the skin and so cause acne or boils. Different skin lubricants may be used: glycerine, vaseline, lanoline, lard, “cold cream,” olive oil, cocoa butter, etc. Glycerine I definitely condemn, since its strongly hygroscopic properties make it irritating to the skin; vaseline irritates somewhat. Liquid oils are troublesome to handle. Solid cocoa butter is better, but it has a fairly strong smell. On the whole it seems to me that lard should have the preference.
Some masseurs use only talc or other powders. In general massage this often seems to me most comfortable for the patient. If, however, the masseur has the good fortune to possess really dry hands he can give general massage without either powder or lubricant.
For deep effleurage, especially over the forearms or legs, it is sometimes necessary to shave the part once or twice a week, otherwise “pimples” may arise.
The masseur’s hands must be carefully washed immediately before and after each séance; the nails should not be too long, and no rings should be worn.
The whole material outfit* [See Footnote at bottom of column] needed by a masseur (besides the above mentioned lubricant) consists of a couch of suitable length and breadth, and about 60 cm. high, accessible from all sides, a so-called plinth, preferable with one end which can be raised or lowered according to need. When massage is given to any part of the back, buttocks, chest, abdomen, pelvis or legs, sometimes even to the shoulder joint, the patient lies on the plinth and the masseur stands or sits beside it. When massage is given to the lower part of the arm up to and including the elbow joint, the patient and the masseur sit directly opposite each other, one on either side of the plinth (upon which the patent rests his forearm). For massage of front or back of neck the patient sits on the plinth, and the masseur strands in front in the first case, behind or beside in the second. The suitable position for the patient is in most cases obvious. Where this is not the case we shall return to the subject in the special chapters.
|There are many different forms of massage according to the anatomical conditions. Generally massage is local and is applied only to a small part of the surface of the body, but it may also be applied to the greater part of the body, and is then called general.
The different forms of local massage are described later in their proper places; for practical reasons, and to make the study of the physiological and general therapeutic effects mentioned in the next chapter easier for the reader, we give here a short description of the technique of massage of the front of neck and of the abdomen as well as of general massage.
|Massage, or rather effleurage, of front of neck * (5) aims at hastening the circulation in the area of the bloodvessels concerned, which are for this purpose favourably situated anatomically. With the palmar surface of each hand pressed against the corresponding side of the patient’s neck, and with both hands together, the masseur passes his hands several times from above down with rather firm pressure over the jugular veins in as much of their course a possible, at the same time avoiding pressure on the hyoid bone or larynx (see Fig. 23.)|
|Fig. 24 shows the method of giving effleurage of front of neck used by Höffinger and others, standing behind the patient, which seems to me more comfortable and better than standing in front. The illustration is not quite satisfactory, as it gives the impression that the strongest pressure is given near the mid-line.|
|In case of necessity Gerst allows the patient himself to massage the front of the neck, using first one hand and then the other, with the thumb on the corresponding side of the neck passing down over the common jugular vein; the other fingers work over the veins of the other side of the neck.
Effleurage of front of neck is performed with constantly repeated stroking for about ten minutes at a sitting; the number of sittings advisable in acute cases may be as many as five or six a day.
In such cases a lubricant is useful. Massage of front of neck is preferably given by a doctor, but may be entrusted to others as Gerst has shown.
| Abdominal massage or “abdominal kneading” aims at manipulating the alimentary canal through the abdominal walls, and is generally given (see later) for chronic constipation. The masseur, holding his fingers hyperextended, place the palmar surface of the three apposed middle fingers over the part which is for the moment to be massaged, with moderate force presses in the abdominal wall,
and, by means of small circular manipulations with steady pressure, kneads or rubs the corresponding part of the alimentary canal, between the anterior and posterior abdominal walls (see Figs. 25,26). The patient’s skin moves with the masseur’s fingers and a lubricant is unnecessary. During this manipulation the masseur keeps his hand fixed in slight dorsal flexion at the (upper and lower) wrist joint, and in the sitting position the movement is divided between the elbow, shoulder, and hip joints. One hand is used at a time, the right and left moving alternately.
|In massage of the stomach this manipulation is applied over the gastric and left hypochondriac regions, but reaches only a small part of the organ if it is approximately normal in size. If the stomach is dilated it is to that extent more within reach of massage. By performing the above manipulation more staccato (more after the manner of tapôtement, although the fingers do not leave the abdominal wall), for example, over an atonic or dilated stomach, one can give a stronger mechanical stimulus than by means of the smoother pressure to the non-striated muscle and so produced contraction. Among Zander’s apparatus there is a vibrating pellet which vibrates from side to side; by leaning against this with the part of the abdomen required the patient receives a forcible shaking over the stomach and bowels.|
In manipulating the large intestine one begins over the cæcum, then going over the ascending, transverse, and descending colon and sigmoid flexure down to the symphysis pubis, paying careful attention to every 1/4 cm. of bowel, except those parts (the hepatic and splenic flexures) which for anatomical reasons cannot be reached. The small intestine is got at by similar manipulations over the umbilical and lumbar regions. In very sever cases of chronic constipation one should insist on treatment twice a day. The effect of the treatment depends essentially on the manipulation being performed long enough on each part of the bowel before the fingers are moved on to the next; the whole séance should occupy at least fifteen minutes.
|To empty the contents of the large intestine into the rectum one can afterward with one hand – or better and more strongly with one hand applied over the other to strengthen it, only one hand coming in contact with the patient’s skin – perform stoking over the large bowel, especially over the transverse and descending colon and sigmoid flexure. One can also attain this object by placing the hands one over the other (see Figs. 27 and 28), and constantly moving first the under, then the upper hand a little at a time and without for a moment relaxing the pressure on the bowel. In this one does not press directly downwards all the time, rather upwards, but the whole procedure, which ends over the symphysis pubis, is extremely effective in emptying the contents of the large intestine into the rectum.|
|In ordinary cases there is no great necessity for the doctor to perform the abdominal kneading, and no danger in leaving it after some instruction to non-medical workers, although it then seldom gives such good or rapid results even when performed in the simple and effective manner above described. It is noteworthy and interesting that, in spite of the extreme simplicity of abdominal kneading and the eagerness of my pupils to learn it, I have great difficulty in getting them to do it properly; and I understand more readily since I have begun to teach these subjects how it happens that so few masseurs can perform the “miracles” so easily obtained in severs cases of chronic constipation. I will refer again to this subject at the end of the next chapter and in the chapter on Diseases of the Alimentary Canal and Abdomen.|
|The above-described simple technique is that which for nearly a quarter of a century I have found most effective while experimenting with different manipulations on a large number of patients with chronic constipation, and I think from my experience I am giving the reader good advice when I beg him not to waste time on other less effective or quite ineffective manipulations by whatever masseur they are recommended. Many classes of manipulations, so warmly recommended in some quarters, with circular strokings round the umbilicus, with pressures over the cœliac plexus (half-way between the ensiform process and the umbilicus), and over the splanchnic plexus (half-way between the umbilicus and the symphysis pubis), with sacral beating, etc., are empy “ornaments,” or at least of very doubtful and certainly subordinate value, and one only wastes time over the. Stroking over the colon, strongly performed with one had, or with one hand over the other, are certainly capable for the moment of sending the contents of the bowel into the rectum, and thus promote, also for the moment, a more immediate action. But this is not the chief aim of the treatment (see next chapter), and the same result is obtained by the manipulations already recommended, which in all their simplicity, when conscientiously performed, gain their end with certainty, although, in sever cases of chronic constipation, often not till after several months’ treatment.