The Art of Massage J. H. Kellogg, M.D. 1895   THE PROCEDURES OF MASSAGE.  
 
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    All the different useful procedures in massage may be classified under seven heads, as follows:

    1. Touch.
    2. Stroking.
    3. Friction.
    4. Kneading.
    5. Vibration.
    6. Percussion.
    7. Joint Movements.

    Under each of these heads we have several subdivisions, which must be separately considered.
 

TOUCH

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    The touch of massage is not simply an ordinary touch or contact of the hand with the body, but is a skilled or professional touch. It is a touch applied with intelligence, with control, with a purpose; and simple as it is, is capable of producing decided physiological effects. This procedure has three different forms of application ; viz., passive touch, pressure, and nerve compression.

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    1. Passive Touch (Fig. 34). - This consists in lightly touching the part operated upon with one or more fingers, with the whole hand, or with both hands.

    Physiological Effects. - The physiological effects of simple touch are :

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    (1) Elevation of the temperature of a part by the communication of animal heat.

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    (2) A subtle influence upon the nervous system-the socalled hypnotic effect, not due to any occult force exerted or mysterious qualities possessed by the operator, but simply the reflex influence through the cutaneous nerves upon the centers of the brain and cord, of the gentle contact of a warm, soft hand with the skin.

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    (3) It is possible that certain electrical effects may result from simple contact of the hand of the masseur with the body of the patient (38).

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    The effects of simple touch are quite remarkable. Some persons seem to be especially sensitive to its effects, and feel, or imagine they feel, a peculiar influence emanating from the operator, to which the term “magnetism" has sometimes been applied. The hypnotic state is produced in some very susceptible individuals by, simple passive touch. The peculiar influence attributed to the touch of certain persons is due, not to any occult power, but to subtle qualities of manner, a peculiar softness of the hand, or some other personal quality not easy to describe.

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    Therapeutic Applications. - Touch is often remarkably effective in relieving hyperaesthesias, especially in the region of the head and joints. Pain is lessened, and numbness, tingling, and other sensations are made to disappear. Sleeplessness may also be, relieved, and nervous irritability quieted, by simple contact of the band with the head.
    In applications of touch for therapeutic purposes, it is important that the utmost quiet should be preserved. The patient should be required to shut his eyes, if the application is made for the relief of insomnia or general nervous irritability, and should not be allowed to speak, neither should he be spoken to. All noises and disturbing causes should be suppressed, as it is desirable that the patient's mind should become as quiet as possible, and that the sensorium should be protected from the disturbing influence of sensory impressions of every sort.

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    2. Pressure. - This consists in making light or heavy pressure with the whole of one or both hands or with one or more fingers, upon the head, a joint, or some swollen or irritated part, or upon any portion of the body.

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    Physiological Effects and Therapeutic Applications. - The effect of pressure is to diminish swelling and congestion, and thus to relieve pain. Violent headache or pain in a joint may often be relieved in this way. A person suffering from severe toothache involuntarily makes firm pressure against the painful part. Pressure relieves pain, doubtless both by emptying the blood vessels and by benumbing the nerves.

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    3. Nerve Compression (Fig. 35). - In this procedure strong pressure is made upon a nerve trunk at some point in its course. The points usually selected for pressure are the so-called  “motor points,” which are located upon the surface where large nerve trunks are readily accessible, lying just beneath the skin. The accompanying cuts (Figs. 32 and 33) show at a glance the points at which the principal nerves may be most easily reached. The spinal nerves are 'compressed by placing one finger on each side of the spine and making firm pressure opposite the spaces between the vertebrae.

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    Physiological Effects. - The physiological effect of light pressure upon a nerve trunk is that of stimulation. The slight irritation produced by the pressure is transmitted to the nerve centers which give rise to the nerve operated upon, and thus both the nerve trunk and its centers may be, by repetition of the pressure, excited to almost any degree desired. A good illustration of the stimulating effect of pressure upon the nerve trunk is afforded by the coughing produced by light pressure upon the pneumogastric nerve in the neck, just above the sternum.

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    Firm, deep pressure, continued for some little time, produces numbness and may even paralyze the nerve trunk, thus giving rise to a sedative effect. An illustration of this is found in the well-known sensation resulting from a blow upon the ulnar nerve at the point where it comes near the surface, just behind the elbow. The numbness of the little finger and of the inner side of the fourth finger thus induced may last for some minutes, if the pressure or blow has been sufficiently severe.

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    Stimulation of the pneumogastric nerve is produced by pressure at either side of the larynx just above the upper end of the sternum, the finger being carried backward and slightly below the level of its top, until resistance is felt by the compression of the tissues against the spine.  This, however, is a measure which must be used with the greatest care.  It should never be employed except under the advice of a physician.  Sufficient pressure might easily be applied to produce grave symptoms in a sensitive patient (Fig. 35).

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    One of the most interesting and striking illustrations of the sedative effects of nerve compression is to be found in the application of this measure to the abdominal sympathetic when in a hypersensitive or hyperaesthetic state.  For this purpose the application should be made as follows : With the patient lying upon the back, the knees drawn up and the feet supported, the head-not the shoulders-resting upon a pillow, so as to relax the abdominal muscles, pressure is made at three points respectively, two inches on each side of the umbilicus, and two inches below this point.  The tips of the fingers should be placed upon these points in succession, and pressed firmly and. steadily toward the spinal column until resistance is felt.  Sometimes the surface is so sensitive that the patient contracts his abdominal muscles so firmly that but slight impression can be made upon the tense abdominal wall.  In such a case it is necessary to divert the patient's attention from his abdominal muscles.  This can be done by making him breathe deeply and regularly.  With each expiration, carry the fingers a little deeper into the tissues, until they are pressed against the anterior surface of the spine.  The patient will experience some pain when the pressure falls, as it should, directly upon the lumbar ganglia (one on each side of the umbilicus) or the subumbilical ganglion or lumbo-aortic plexus, located two inches below the umbilicus (Fig. 76).
    Without making hard pressure, the ganglia, when found, should be rubbed and pressed intermittently for half a minute, at intervals of two or three minutes.  After a few applications the sensitiveness will be found to have disappeared either wholly or in part, unless the cause still continues active.  Too great pressure must not be applied at first, as nausea, faintness, and even-prolonged pain may thereby be produced.

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    Therapeutic Application. - Pressure is extremely useful in connection with joint massage, affording a means of emptying the veins and lymph spaces and vessels.  It should be employed in connection with friction and kneading as a means of emptying the large veins and lymph vessels which are found in the region of the joints.

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    Nerve compression is either stimulating or sedative, according to the manner in which it is applied.  By a repetition of stimulating applications to the nerve trunk, important alterative effects may be produced, rendering this mode very valuable in many cases of sciatica accompanied by structural changes in the nerve trunk, also in paralysis.

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    Nerve compression is one of the most valuable means of arousing the activity of the nerve centers, through the indirect stimulation induced by this procedure.

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    In the application of nerve compression in cases of paralysis, the pressure should be light and intermittent, repeated four or five times, the pressure lasting not more than two or three seconds, with an interval of five or six seconds.

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    For general stimulation of the spine, make firm pressure with the thumbs close to the spinous processes and opposite the spaces between the spines, or between the ribs near the spine.

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    In facial neuralgia, pressure may be made upon the seat of pain or at the nearest point at which the affected nerve is accessible from the surface.

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    Intercostal neuralgia is relieved by pressure applied to the intercostal space at the seat of pain, the pressure being directed toward the lower border of the uppermost rib.

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    In sciatica and crural neuralgia, pressure may be applied to the affected nerves (Fig. 25).  In sciatica, pressure should be made at the points along the junction of the sacrum and ilium, as well as over the sciatic nerve in the hollow of the thigh.  The pressure should be sufficient to cause some pain, and should be continued until the pain ceases or the nerve becomes numb.
    Pressure is uniformly made, in nerve compression, upon the points at which nerve trunks are most easy of access.  This procedure is one that needs to be employed with very great discretion.
 

STROKING

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    This procedure (Fig. 36) is simply touch combined with motion. The tips of two or three or of all the fingers, or the entire palmar surface of one or both hands, should be moved gently over the skin with light contact. In gentle stroking, not even the full weight of the hand is allowed to rest upon the surface, the contact being made as light as possible.

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    The direction of the strokes, or passes, in application to different parts of the body, is as follows:

    Head, from before backward, starting at the center of the forehead, and from above downward, starting at the vertex.
    Back, from above downward and from the median line outward.
    Chest, from the sides toward the median line.
    Abdomen, upper part, from the sides inward and upward; middle part, toward the median line; lower part, from below upward and inward.
    Arms, from the shoulders toward the hands.
    Legs, from the hips downward.
    Feet, from the toes toward the heel.

    The wrist must be flexible, and the movement even and slow, and perfectly uniform in relation to pressure and time.

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    Rate of Movement. - The number of passes per minute will, of course, depend upon the extent of surface covered by each stroke, but the hand should not be allowed to move at a more rapid rate than one or two inches per second. The stroking may be repeated many times upon the same place - from two or three minutes to half an hour, or until the desired effect is produced.

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    Stroking is always done in one direction only, never to and fro.  As a rule, the direction of stroking should be that of the blood current in the arteries, outward or downward from the heart.  The direction, as a rule, is the opposite of that of friction.  When applied to hairy surfaces, the stroking should be in the way the hair lies, not against the hair, as in “rubbing a cat's back the wrong way.”

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    There are several forms of stroking:

    1. With the finger tips, digital stroking.
    2. With the palm of one or both bands, palmar stroking.
    3. With the knuckles, knuckle stroking.
    4. Reflex stroking.

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    Digital Stroking (Fig. 36). - The tip of one finger may be used, or the tips of all the fingers of one or both hands.  The fingers are held very slightly apart, a little curved, and in a flexible condition, so that all the fingers will fall lightly in contact with the surface.  Stroking with the finger tips is used chiefly for the forehead and spine.

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    Palmar Stroking. - In this procedure the whole or a part of the palm of one hand, or the palms of both hands, should be applied to the surface.. It is used for broad, fleshy parts, about the joints and for the soles of the feet.

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    Knuckle Stroking. - In this procedure the hand is closed, and the knuckles of the second joints of the fingers are applied to the surface.  It is seldom used except in massage of the back.

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    Reflex Stroking (Fig. 37). - In this form of stroking, which, so far as the writer knows, has not been previously described, or systematically employed by others as a therapeutic measure, applications are made exclusively to those parts of the body which have been described, by physiologists as areas which may be employed in developing the so-called cutaneous, or skin, reflexes.  Light stroking applied to these surfaces produces muscular contraction as the result of the formation of a reflex arc through the spinal cord.  These reflexes are exceedingly well marked in those persons who are said to be ticklish. The reflex is developed by gently stroking the sensitive part with the finger nail. The end of a lead pencil, a wooden toothpick, or the head of a -pin may also be employed.

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    Reflex Areas. - The principal areas which have been described as particularly susceptible in producing reflex influences, are the following:

    (1) The skin of the back between the scapulae, or shoulder  blades; (2) The sides of the chest, between the fourth and sixth ribs; (3) The skin of the abdomen in the mammary  line; (4) The surface at the upper and inner portion of the thighs; (5) The skin overlying the gluteal muscles; (6) The  sole of the foot. The writer will venture to add to this list, as  the result of his observations, another reflex area ; namely, (7) The skin of the axillary region, which in some persons is exceedingly sensitive.

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    The various reflexes are named partly from their location and partly from the muscular effects produced reflexly by their stimulation, as follows:

    Interscapular.
    Epigastric (produces movement at the epigastrium).
    Abdominal (causes contraction of the abdominal muscles on one side).
    Cremasteric (causes contraction of the cremasteric muscle in males, and probably of the round ligament in females).  The writer has noticed that stimulation of the skin of the cremasteric area in girls and women causes a muscular contraction just above Poupart's ligament and in the region of the inguinal canal.  This same reflex was observed in the case of a young man whose development had assumed the feminine type in consequence of arrest of development of the testicles.
    Gluteal.
    Plantar (causes contraction of the muscles of the thigh).
    A seventh may be termed the axillary.

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    These reflexes affect not only the cutaneous nerves and muscles which are seen to act as a result of the local surface stimulation, but necessarily also the nerve centers.  The particular portions of the cord acted upon in connection with the several reflexes are as follows :

    Interscapular, - sixth to eighth cervical and first dorsal segments.
    Epigastric, fifth to seventh dorsal.
    Abdominal, eighth to twelfth dorsal.
    Cremasteric, first to third lumbar.
    Gluteal, fourth and fifth lumbar.
    Plantar, fifth and sixth sacral.
    The axillary reflex, if admitted, is in relation to the second, third, and fourth dorsal, or that portion of the spinal cord lying between the areas excited by the interscapular and the cremasteric.

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    It is a curious fact that firm pressure upon the reflex areas does not develop the reflex, whereas very light stroking may, produce so powerful a reflex that one or both limbs will be suddenly drawn up. The reflex is also excited by cold.

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    Physiological Effects. - Digital and palmar stroking, when properly applied, have a decided sedative effect ; but it is important that the application should be made in a proper manner, - with very light contact, and in the direction of the blood current in the arteries.

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    In friction, the purpose is to increase the circulation of the skin and excite activity, hence the movement is in the direction of the venous blood current. The purpose of stroking is the opposite; namely, to diminish the blood supply. The race horse is always rubbed down after violent exercise. The athlete also has himself rubbed in the same manner, after a contest.
    Stroking, even when very light, also produces a peculiar effect upon the cutaneous nerves, the action of which, when applied to certain regions at least, seems to be strongly sedative and remarkably quieting.

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    Knuckle stroking is stimulating. It might, perhaps, be more properly called friction than stroking, as it is applied with more pressure than ordinary stroking. . The purpose, when applied to the back, is to excite the posterior branches of the spinal nerves, and thus stimulate the spinal centers.

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    Reflex stroking is certainly a most powerful means of stimulating the centers of the cord.  It must not be supposed that the muscular actions induced by reflex stroking are the sole effects produced.  Very active reflex relations exist between the entire cutaneous surface and internal parts.  The reflexes named are especially designated for the reason that the muscular effects produced are so apparent as to render them easy of observation and study. The same nerve centers which send
branches to the muscles involved in these reflexes, also send branches to internal parts.

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    It must not be forgotten that the organic reflexes, those concerned with the genito-urinary functions and those of defecation, as well as those of secretion and motion as concerned in digestion, have their seat in the spinal cord, so that the same stimulation which excites the gluteal and cremasteric reflexes must also excite, more or less, the nerve centers which control the digestive and the genito-urinary functions.

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    Therapeutic Applications. - Gentle stroking of the forehead in many cases affords relief from sleeplessness. It is not an uncommon thing for a patient to fall asleep under what might be termed the hypnotic influence of gentle digital or palmar stroking of the head. Palmar stroking .of the feet will in many cases produce the same effect, especially when employed in connection with stroking of the limbs.

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    Stroking may also be employed advantageously after other procedures in massage, for the purpose of lessening an excessive degree of cutaneous congestion or stimulation which may have been produced. It is especially useful for this purpose when  applied about a joint. It is also of value as a means for relieving hypersensitiveness, even when accompanied with inflammation. Certain forms of nervous headache may frequently be controlled in a most decided manner by gentle stroking of the head.

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    Neuralgic pains, likewise, are sometimes much alleviated by this means, as are numbness, formication, and a great variety of neurasthenic pains and paraesthesias.  Stroking of the forehead produces in some persons a hypnotic effect which is more or less pronounced according to the temperament of the individual.  This effect is rarely ever pronounced-except in hysterical cases.  It is due not to any magnetic or occult influence on the part of the manipulator, but simply to the reflex influence of the nerves involved, acting upon the volitionary centers.

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    Reflex Stroking is applicable to a variety of conditions, especially the following:

    1. Interscapular stroking, used advantageously in spinal anaemia.
    2. The epigastric reflex, excited advantageously in hypopepsia and motor insufficiency of the stomach.
    3. Abdominal reflex stroking, especially useful for the relief of constipation and a relaxed condition of the abdominal muscles.  It should always be used in connection with abdominal massage.
    4. Gluteal and cremasteric reflex stroking, advantageously employed in cases of loss of tone in the rectum or the bladder, or in weakness of any of the genito-urinary functions.
    5. Plantar stroking, usefully employed in cases of the last named sort, as well as in all others in which it is especially desired to improve the innervation of the muscles of the lower extremities.
 

FRICTION

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    In this procedure the whole or a part of the hand is moved over the surface with a considerable degree of pressure, the amount varying in different parts-heavy over thick, fleshy masses, light over bony surfaces and thin tissues.  The amount of pressure, however, should never be such that the hand will not readily slip over the surface, nor so great as to interfere with the movement of the blood in the arteries.

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    The principal effect of friction is upon the superficial veins, the large venous trunks, and the lymph spaces and vessels.  In the application of friction, the thumb only, or the whole or a greater part of the palmar surface of the hand, is brought in contact with the part operated upon.
    Five different forms of friction may be described as follows:

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    Centripetal friction (Fig. 38), in which the movement is in the direction of the blood current in the veins, chiefly applicable to the extremities, the movement being from below  upward, and from the hands and feet toward the body, the thumb or palmar surface of the hand being employed.

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    Centrifugal friction, in which the movement is opposite to that of the blood current.

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    Circular friction (Fig. 39), applicable to the extremities.  The limb is grasped by both hands, which make an alternate  wringing or twisting movement, beginning at the hand or foot and extending upward.

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    Spiral friction (Fig. 40), a sort of combination of the preceding, executed with one hand, which progresses from the lower, or distal, to the upper, or proximal, end of the part with a sort of spiral movement.

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    Rotary friction (Fig. 41), in which the hands are made to move over a broad surface in an elliptical, circular, or semicircular direction; especially applicable to such fleshy areas as the hip and that portion of the back lying above the spines of  the scapulae. In applying rotary friction, it is often necessary for one hand to support the tissues while the other hand is executing the movements.

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    Rate of Movement. - The rate of the movement will necessarily vary according to the length of the stroke, and hence differs in different parts of the body. The rate may be varied from thirty to one hundred and eighty strokes per minute.

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    Direction of Movement. - The direction of the movement in friction must necessarily vary more or less, according to the part operated upon. The general rule is to follow the large veins. Special care should be taken, in the treatment of the extremities, to follow the large venous trunks, making firm pressure directly over the large veins with the thumbs, passing from below upward.

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    In the treatment of the forearm, the masseur will give special attention to the radial vein, which runs along the outer and anterior portion of the forearm ; the anterior and posterior ulnar, which course along the anterior and posterior aspect of the inner border of the arm; and the median, which lies along the middle of the anterior surface of the forearm (Figs. 23 and 24).

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    In the upper arm, special attention will be given to the cephalic along the outer side, and the basilic along the inner side, of the arm (Fig. 23).

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    In applying friction to the leg, the thumb should at first be passed with firm pressure over the long saphenous, the course of which is from the instep along the anterior and inner portion of the leg to the groin ; and the short saphenous, the course of which is from below the outer malleolus along the outer and posterior portion of the leg to the bend of the knee (Fig. 25).

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    Friction is applied to the following parts in the direction designated:

    Head, from before backward, and above downward.
    Neck, downward.
    Back, above shoulder blades, circular, from shoulder blades to sacrum, down; in the region of the loins, from the sides toward the spine.
    Hips, circular.
    Chest, from the sternum toward the axilla.
    Abdomen, upper part, from above downward and outward;  lower part, from the median line downward and outward.
    Arms and legs, from below upward.

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    To promote absorption, rub toward the heart (centripetal friction).

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    For sedative and derivative effects upon the viscera and nerve centers, rub downward (centrifugal friction).

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    Rubbing upward, or in the direction of the venous blood current, increases the activity of the circulation.

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    Rubbing downward decreases vascular activity.

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    In the application of friction, pressure should always be uniform for the part operated upon, and should be carefully graduated to meet each particular case.

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    As a rule, some lubricant should be used. Fine vaseline, cocoanut oil, cacao butter, and talcum powder are the best lubricants.

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    Friction is applicable to all parts of the body, but is especially useful to the limbs, head, and neck. It should always be used at the beginning of the application of massage, if the surface is cold.

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    In the application of friction to large parts, both hands should be used, either together or in alternation. In the treatment of a part which is small, it may be steadied by one hand while being treated by the other.

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    Mode of Applying Friction to Different Parts. - A systematic order and method is essential in the application of friction to different parts of the body, which may be described for the chief divisions of the body as follows:

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    The Hand. - The patient's extended hand being allowed to rest in one hand of the operator, with the dorsal surface up, the masseur holding the fingers of his other hand firmly extended, applies the tips of his fingers to the patient's hand in such a way that they will fall into the grooves between the adjacent fingers and metacarpal bones.  The fingers are then pushed along in these grooves from the roots of the nails to the wrists.  After repeating the movement several times on the back of the hand, the patient's hand is turned so that the palmar surface will be up, and the same movement repeated as before, with the modification that the fingers are carried a little farther up the wrist until the heel of the operator's hand rests in the hollow of the patient's hand, when slight rotary movement and firm pressure should be made, for the purpose of compressing firmly and emptying the numerous veins of the fleshy portion of the palm.
    The movements upon the back of the hand should be at the rate of sixty a minute; on the palmar surface a smaller number of movements will be executed per minute on account of the pause for three or four seconds in making rotary friction in the palm after each centripetal stroke.

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    The Forearm. - With the arm of the patient half flexed, the  masseur, facing the patient and operating with both hands, should make strokes from wrist to elbow, first with one hand upon one side and then with the other hand upon the other side of the arm, in such a manner that each hand will include one half the circulation of the forearm, both thumbs resting upon, the front of the arm. The operator may, if he prefers, stand with his back to the patient, making the strokes alternately with the two hands, as before.

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    The masseur should keep constantly in mind the fact that firm pressure is to be made only with the ascending friction stroke. The hand is allowed to glide lightly over the surface in the descending or stroking movement, as a soothing measure, and not for the purpose of applying friction.

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    In the treatment of very feeble persons the patient may  be too much fatigued if the operator works with both hands at once, thus leaving him to support his own arm. In such case the patient's arm should be supported by the masseur, who will  grasp the patient's right hand with his own right hand, or the  left hand with his left, applying spiral friction (Fig. 40) with the other hand upon the front side of the arm, then changing  hands to operate upon the back of the arm.

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    The Arm. - Work the arm in a manner similar to that described for the forearm.

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    The Shoulder. - In applying friction to the shoulder, the  masseur faces the side of the patient, operating with the two hands in alternation, following the surface of the joint, and always taking care to work centripetally; that is, toward the  heart or toward the center of the body, and taking pains to follow the irregularities of the surface. The under as well as  the upper side of the shoulder should receive attention.

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    The Foot. - Begin as with the hand, by friction with the ends of the fingers upon the dorsum of the foot, the operator standing in such a position as to face the sole of the foot. After finishing the dorsal surface, change the position so as to face the side of the foot, and make alternate transverse movements with the two hands on both sole and dorsum, working  vigorously from toes to heel and instep. Lastly, extend the friction movements to the ankle, working with both bands, and following up the grooves on each side of the tendon Achilles.

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    The Leg. -  With the leg half flexed upon the thigh, standing facing the patient, the masseur applies friction to the calf of the leg from ankle to knee, making eight or ten strokes,  then turns his back to the patient, and operates upon the front of the leg by means of the thumbs working in alternation.

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    The Thigh. - Standing with his back to the patient, the masseur grasps the leg in such a manner that the fingers fall behind and the thumbs in front, and makes very firm but rather slow strokes from knee to groin, not forgetting to give the knee due attention.

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    The Chest. - The patient's arms should be separated a little from the sides, so as to straighten the outer portion of the pectoral muscles. The masseur, standing at one side, and facing  the patient's feet, makes strokes from the insertion of the pectoral muscles at the humerus toward the median line, beginning at the upper border just below the clavicle. The two sides may be operated upon simultaneously, or in succession, both hands being employed upon one side, one hand following the other in the movements. In progressing downward, the movement should be reversed below the pectorals, and the hands should be carried as far around the sides as convenient, care being taken to work toward the axilla above, and to follow the direction of the ribs and cartilages, until the whole surface has been covered from the clavicle to the lower borders of the last ribs.

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    The Abdomen. - Facing the patient, the masseur first makes long strokes from the upper to the lower portion of the abdomen, One hand following the other over the recti muscles, the two hands operating simultaneously over the lateral portions. After covering the whole surface six or eight times in this manner, strokes should be made more exactly in the direction of the veins, as follows: At the upper part of the abdomen, make strokes downward and outward, following the
direction of the lower cartilages; for the middle portion, make strokes from the median line outward, reaching around as far as possible; for the lower portion, make the strokes downward and outward, in the direction of the hip joints.

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    The Neck. - Facing the patient, place the hands one on each side of the head in such a manner that the little finger will rest in the groove behind the lower jaw, the other fingers resting upon the mastoid processes, and the inner border of the heels of the hands touching.  Move the hands downward, and at the same time rotate them inward, so as to bring as large a portion of the palmar surface as possible in contact with the neck.  At the lower border of the neck, move the hands
outward toward the shoulders.  After a few strokes, carry the hands a little farther back around the neck, so that as they move downward, the thumbs will rest one on each side of the larynx, thus compressing all the veins of the neck, both the superficial and the jugular, which lie deep.  Finish with a few strokes applied to the back of the neck, starting at the occiput, and carrying the strokes downward and outward to the point of the shoulder.

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    The Face. - Standing facing the patient, the operator places the palmar surface of his hands in contact, then applies them to the patient's face in such a manner that the little fingers touch the forehead at the median line.  Separating the hands at the ulnar border, they are gradually spread out as in opening a book, until the little fingers rest upon the temples and the tips of the thumbs fall at the middle of the forehead.

    Fixing the thumbs at this point, the outer borders of the hands are moved downward by lateral flexion at the wrist until the forefingers fall at a level with the eyes.  The whole hand is then moved downward in such a way that the nose is grasped, and compressed between the thumbs while the palms of the hands and the fingers cover the cheeks. The movement is continued downward, and finished by bringing the hands together below the chin. The object kept in view should be to bring as much of the hand as possible in contact with the face, and to touch every portion of its surface.

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    The Head. - With the patient sitting or half reclining, and the masseur standing behind, the ends of the fingers and thumbs, with the fingers slightly flexed, are placed firmly in contact with the scalp, and a movement executed similar to that employed by a barber in shampooing. The mistake must not be made of applying the friction to the hair instead of the scalp. The movement begins at the vertex, gradually extending to the borders of the hairy scalp.

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    The Hip. - In friction of the hip a very considerable amount of pressure is admissible, as the muscles and fleshy masses are very thick and firm. In applying friction to the hips, the masseur may face either the head or the feet of the patient.

    1. Make rotary friction upon the two sides simultaneously or in succession. In very fleshy persons it will be found necessary to support the tissues with one hand while operating with the other, on account of the great mobility of the muscular mass and the roughness of the skin so frequently encountered in this region of the body.
    2. Apply centripetal friction, working from the great trochanter toward the crest of the ilium, and along the crest of the ilium from behind forward.

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    The Back. - The patient lies upon his face, the masseur facing his head.

    1. A few light strokes are first applied from the occiput to the sacrum, along the center of the back, one hand following the other. The lateral surfaces are then covered by the two hands working simultaneously from above downward, and rotary friction is administered with greater pressure to the fleshy mass lying above the shoulder blade. The two sides may be treated simultaneously or in succession, one hand being used to support the tissues.  The latter method is usually necessary in very fleshy persons.
    2. From the shoulder blades to the hips, lateral strokes are made, the masseur standing with his left side to the patient, facing his feet, the hands being placed as far around the sides as convenient, and simultaneously drawn toward the spine, the movement ending with the hands in contact.  Great care should be taken to follow the ribs in the region of the thorax, which will give the movements a semicircular direction.
    3. Separating the index and middle fingers of the right hand, place one on either side of the spinous processes, and making firm pressure, move the hand downward from the occiput to the sacrum.  The object should be to crowd the ends of the fingers as deeply into the tissues as possible on either side of the spinous processes, so as to influence the dorsi-spinal veins.  If necessary, the left band may be used to increase the pressure.
    4. Finish the back by a few light strokes from above downward, using both hands simultaneously, covering as much surface as possible with the fingers in contact with each other.

229
    Physiological Effects. - The physiological effects of 'riction are somewhat complex.  They may be briefly stated as follows:

    1. Reflex effects upon the vasomotor centers, resulting in dilatation of the small vessels of the skin and increased activity of the peripheral circulation.
    2. Mechanical aid to the movement of fluid in the veins and lymph spaces and channels.  The beneficial effects obtained are largely due to the existence of valves in the veins and lymph channels, by which the fluid displaced toward the heart is prevented from returning.
    3. Friction, which, when applied in a skilled and proper manner, is capable of producing powerful derivative effects.

230
    Reflex or stimulating effects may be increased by using no lubricant of any kind - in other words, making friction upon the dry skin.

231
    Mechanical effects are increased, and the reflex or irritant effects decreased, by lubrication of the skin.

232
    The principal object in the application of friction is to empty the veins and lymph spaces and channels, thus encouraging the circulation. By thus accelerating the flow of the  blood and the lymph, vital exchanges are encouraged, and the tissues are freed from the waste matters which they contain.
    On the whole, friction is one of the most valuable of the various methods of procedure in massage.

233
    All the functions of the skin are especially stimulated by friction. Under the application of friction, a dry skin becomes moist and oily through the increased activity of the perspiratory and sebaceous glands. It is also a common observation  that friction promotes the development of the hair upon the parts to which it is applied. Professor Winternitz and his students have shown that by the application of friction to the skin, the amount of moisture thrown off may be increased sixty per cent and the dissipation of heat more than ninety-five per cent.  Under the influence of friction the temperature of the skin is raised to a very marked degree, both through the dilatation of  the surface vessels, which brings more blood to the surface, and by increased production of heat. This is, of course, the cause of the increased heat dissipation under the influence of friction.

234
    Therapeutic Applications. - Friction is usually employed therapeutically in conjunction with kneading and other movements, being used in alternation with other procedures.

235
    The reflex or stimulant effect of friction is useful in all cases in which the peripheral circulation is defective.  Care must be taken in the employment of friction for stimulative effects, that the skin does not become abraded by too long manipulation without lubrication.  From five to eight minutes is as long a time as it is safe to apply friction to the dry skin.

236
    The mechanical effects of friction, by aiding the venous and lymph circulations, are among the most valuable of all the results to be obtained by massage.  It is by the acceleration of the circulation, by means of which a larger supply of white  blood corpuscles is brought to the affected parts, thus encouraging phagocytosis (85), that friction is of great value in the treatment of inflammatory exudates, such as usually occur  about joints. When used for this purpose, the friction should be applied in alternation to the affected par and to the tissues between it and the heart.

237
    Friction is especially useful in general dropsy, and in all forms of local swelling, whether due to inflammation or to congestion resulting from a mechanical cause acting upon the circulation. Its efficiency in promoting absorption renders it of great value in sprains, chronic joint enlargements from various causes, sciatica, rheumatism, gout, and even in glandular enlargements. In the treatment of such affections, massage should first be applied to the diseased part and then friction, by
  the centripetal method, to the tissues between it and the heart.

238
    The derivative effects of friction are of great value in the treatment of inflamed joints, painful sprains, pelvic pains, insomnia, and local congestion of various sorts. In cases of  local   inflammation the application should not be made directly to the affected or inflamed part, but between it and the heart. By this means the part may be drained of its surplus blood and the inflammatory process thus be rendered less active or checked altogether. In the case of an inflamed joint or muscle, friction, by operating upon the superficial vessels, diverts the blood from the affected part, causing it to go round instead of through it.

239
    Pelvic pain may often be alleviated by friction of the lower part of the back.  Headache may be relieved by friction of the spine.  Cerebral congestion, and the insomnia resulting from it, may often be relieved by centrifugal friction applied to the extremities.  The rubbing should be in a direction away from the heart, thus impeding the flow of venous blood and so retaining a considerable amount of blood in the lower extremities, and thereby affording relief to the congested brain.

240
    In cerebral congestion the rubbing should always be downward.  In anaemia of the brain, rub upward.

241
    Friction is of value in all conditions of the skin in which its normal activities are impaired.  “Hidebound” skins, and conditions in which the skin is dingy, tawny, jaundiced, cold or otherwise inactive, are benefitted by the application of massage.
 

KNEADING.

242
    This is, perhaps, the most important of all the different manipulations in massage, and of all the various procedures is that to which the term massage is most appropriately applied, since the meaning of the word is to knead, as a baker kneads dough.  In all its varieties, this procedure consists essentially in the application to the tissues of alternate and intermittent compression, by grasping the tissues or by compressing them against underlying bony surfaces.  Kneading differs essentially from friction in that the skin of the parts grasped or compressed is held in firm contact with the surface of the hand of the operator, the hand not being allowed to slip along the surface of the skin, as in friction.

243
    The different forms of kneading may be divided into two classes; viz.: (1) Superficial and (2) Deep.  There is but one mode of applying superficial kneading, viz., pinching or fulling, but deep kneading. may be applied in a variety of ways, the most important of which are petrissage, rolling, wringing, chucking, palmar kneading, fist kneading, and digital kneading.

244
    1. Superficial Kneading, or Fulling (Fig. 42). - In this procedure the skin is grasped between the thumb and the last two phalanges of the first finger, or in cases in which the skin is very thick, the terminal phalanges of the first and second fingers may be used in opposition to the thumb.  The procedure is essentially a pinching movement which acts exclusively upon the skin and the loose cellular tissue underlying it.  The skin is simultaneously compressed between the thumb and finger
and lifted from the underlying bone or muscle, being released at the moment when the strain is the greatest, so as to secure the maximum effect in emptying and refilling the blood vessels and lymph spaces and channels.
    The two hands are used in alternation, one hand picking up the tissue as the other drops it, and so following along over the surface in a systematic manner. The direction of the movement in relation to the veins is not important, as this form of manipulation is commonly used in alternation with centripetal or spiral friction movements.

245
    Physiological Effects and Therapeutic Applications. - Superficial kneading stimulates powerfully all the functions of the skin, and hence is useful in all cases in which any of the functions of the skin are impaired. It is especially indicated in jaundice, and in cases in which the skin is dry or "hidebound."

246
    2. Deep Kneading. - In deep kneading the object is to act upon the muscles. There is no procedure in massage which requires so much skill, discretion, and anatomical knowledge  as deep kneading, since it is necessary to keep constantly in mind the quality of the tissues acted upon, the general condition of the patient, the form of the muscle or muscular group under treatment, and the outline of the individual bone underlying the parts undergoing treatment. The location of the large
blood vessels and nerves must also be accurately known and kept in mind, as these structures may easily be injured by the  application of too much force.

247
    Comparatively little pressure should be used in kneading thin tissues; thick, firm tissues admit of much greater pressure. It is also important to remember that a tolerance of pressure is established by prolonged treatment so that while very gentle pressure only should be applied at the beginning of treatment, the force may be gradually increased until almost the whole strength of the. operator may be employed without injury to the patient.

248
    Petrissage (Fig. 49). - By this term is designated that form of deep kneading in which the muscular structures are grasped by the hand very much as a baker grasps a mass of dough. The tissue is not grasped between the ends of the thumb and fingers, but the skilled masseur employs as large a portion as possible of the palmar surface of the hand, taking care to keep the fingers close together.  The fingers should not be opposed by the end of the thumb but by the thenar eminence, or the fleshy portion of the thumb.  By this means the force employed is spread out over a large surface, and so is transmitted to the deep tissues instead of being expended upon the skin, as would otherwise be the case.

249
    Great care should be taken to prevent slipping of the skin between the fingers. The movement of the tissues should be in the deeper parts, but so great pressure should not be applied  as to prevent the deeper parts from gliding easily over the still deeper lying structures or bones.

250
    In petrissage the parts should not only be squeezed or com pressed in the hand, but should be lifted from the bone or  underlying tissues, rolled and stretched, always in an upward  direction in operating upon the limbs, or from the point of  insertion. Each time a muscle is grasped, it should be at the same time dragged outward from the median line, by which means it will be lifted from the bone, and the underlying tissues will be stretched. The grasp should be released when the strain is at its maximum, so as to encourage to the highest degree the flow of fluids toward the parts operated upon.

251
    The movements of petrissage should not be executed too rapidly; the rate of movement should be about thirty to ninety per minute. Movements are naturally more rapid in the treatment of small parts, such as the fingers, hand, and forearm, than of such large parts as the thigh.

252
    After the area under treatment has been gone over until each part has been grasped, squeezed, rolled, and stretched four to six times, three or four strokes of centripetal friction should be applied, then the petrissage repeated, so alternating three or four times; then proceed to another part.

253
    The greatest care should be taken to individualize muscles or groups of muscles, so far as possible. This is important, since the blood and lymph circulation of large muscles or muscular groups is to a considerable degree independent, indicating the necessity for separate treatment.

254
    Either one or both hands may be used in petrissage; generally the two hands are used in alternation, one hand following the other, or working upon the opposite side.

255
    Rolling (Fig. 43). - In this procedure the tissues are compressed against the deep-lying structures, and rolled by, a to-and-fro movement. In rolling, the fingers are extended  and held close together. Rolling may be applied with either one or both hands. One alone is used, being, if necessary, reinforced by pressure with the other hand, in the treatment of broad, fleshy surfaces. In the treatment of the limbs, both hands should be used.

256
    If the patient is lying upon the back, the arm will be ex tended upward, the masseur grasping the arm between the two hands pressed against the sides. The movements should begin at the shoulders, the hands of the operator being slowly carried toward the hand of the patient, and moved in alternation in such a manner as to roll the tissues upon the bone. The pressure should be of sufficient firmness, to prevent the hand from slipping upon the skin.

257
    In rolling of the leg, the limb should be placed in a half-flexed position, the movements being applied first to the thigh and then to the leg in the manner described for the arm.

258
    Rate of Movement. - The movement should be executed rapidly - at the rate of two hundred to four hundred per minute. The movement should proceed from above downward, and should alternate with centripetal friction movements; that is, after the whole limb has been rolled from axilla to wrist, or from groin to ankle, three or four centripetal friction strokes should be executed from the lower end of the limb upward.

259
    The degree of pressure used should be considerable in fleshy persons it may be as much as the masseur can apply by lateral pressure of the hands with the arms extended.

260
    Rolling is especially useful in masseing the upper portion of the back, the hips, arms, and legs.

261
    Wringing (Fig.44). - This procedure is executed by grasping the limb with the two hands placed on opposite sides and close together.

262
    Wringing or twisting movements are executed by the hands either simultaneously in the same direction or in alternation. If alternate movements are executed, the hands must be separated a little. Sufficient pressure is employed to prevent the hands from slipping over the surface, as in circular friction.

263
    The movement begins at the shoulder or groin and progresses downward to the wrist or ankle, or it may be made to extend only from one joint to another. This is a very vigorous form of massage, but is obviously applicable only to the arms and legs, and will seldom be called into use.

264
    The movements must not be too rapid; the rate should not exceed thirty per minute.

265
    Chucking (Fig. 45). - In this procedure the limb is supported by one hand while the other firmly grasps the fleshy portion and drags it first upward and then downward in the direction of the long axis of the limb.  These movements are executed two to six times, the hands  traveling along the surface until the whole limb is operated upon.  This application is especially useful in overcoming muscular rigidity and in stretching contracted muscles.  It acts powerfully upon both
blood vessels and nerves.  When employed for the scalp, either one or both hands may be used.

266
    Palmar Kneading (Fig. 53). - This movement is executed either with the heel of the hand or the whole palmar surface, as may be required.  When much force is to be employed, the heel of the hand only is used.  When a large mass is to be masséed, as in mass-kneading of the abdomen, the whole palm may be employed.  It is chiefly used in kneading the back, chest, and abdomen.

267
    Fist Kneading (Fig. 78). - This procedure is used only in kneading the abdomen.  It consists. in compression of the deep tissues by the knuckles of the closed fist. Pressure is made along the course of the colon, beginning in the right groin. The advantage in fist kneading is that the greatest degree of force can be employed, and pressure may thus be communicated to the deepest parts.

268
    Digital Kneading (Figs. 51, 54). - In digital kneading, the ends of the fingers or thumbs alone are employed, the tissues being rubbed and pressed against the underlying bony surfaces; it is used also for operating upon the contents of the colon in abdominal massage. The tip of the thumb or of one finger may be employed alone, or the ends of all the fingers may be used together, the fingers  being held close together and extended. Digital massage is chiefly used in masseing the joints, the spine, the head and face, and the abdomen.

269
    Physiological Effects. - The Physiological effect of kneading is to stimulate all the vital activities of the part operated upon. The nerves, blood vessels, glands, also the cell exchanges and other tissue processes are stimulated. By the  alternate compression and relaxation, blood and lymph vessels are emptied, and fresh blood drawn into the parts, thus effecting a sort of suction or pumping process by which the old blood and poison-laden tissue juices are forced onward, and a new supply of pure and well-oxygenated blood drawn in. Dilatation and quickened activity of the blood vessels are also induced by reflex nervous action. It is the most effective of all means for producing alterative effects and general vital renovation. Under the influence of massage, the parts operated upon become reddened through the increased blood supply,  and acquire a higher temperature, both from the introduction of an increased supply of blood and from a stimulation of the heat-making process in the muscles.

270
    Kneading acts more powerfully than any other procedure in massage, in stimulating heat production.

271
    Therapeutic Applications. - Under the influence of deep kneading, weak muscles increase in size and firmness, demonstrating the value of the method in paralysis and paresis, and in all cases of tissue weakness and relaxation.  By its use, enlarged, stiffened, and painful joints return to a normal condition, and inflammatory exudates are broken down and absorbed.

272
    There is no remedy more valuable in the treatment of muscular and joint rheumatism, sciatica, various forms of neuralgia, general defective development, neurasthenia, writer's cramp, convulsive tic, locomotor ataxia, various forms of chronic spinal disease, and in the opening up of closed lymph and blood channels.  It is also of great value in the treatment of fractures and sprains.  Superficial kneading is especially indicated in dropsy, oedema, jaundice, and all other forms of disease in which the skin is inactive, or in which the functions of the skin are defective.

273
    Mode of Applying Kneading to Different Parts.  Begin either with the hands or the feet.  If with the hands, proceed as follows:

274
    The Hand. - The manipulator grasps between his thumb and finger the terminal phalanx of a finger at the root of the nail.  Intermittent compression is then applied, while the thumb and forefinger of the manipulator creep along up the finger to its junction with the hand.  A sort of pushing and twisting movement is executed at the same time, and attention is given to the sides of the finger, as well as to the palmar and dorsal surfaces.  The thumb and each of the fingers may thus be treated in succession, or both hands may be employed at the same time (Fig. 46).

275
    After finishing the fingers, the manipulator places the patient's hand in one of his own, with the dorsum up, and with the tips of the fingers of his other hand, works thoroughly. between the bones of the patient's hand from the fingers to the wrist ; then, turning the palm of the hand upward, he grasps each side of the palm, and compresses, twists, and rolls the hand in such a way as to draw the tissues away from the median line, to move all the bones, and put a gentle strain upon every
muscle and ligament.

276
    In masseing the wrist, it is seized between the thumb and finger of each hand, the thumbs and fingers following all the irregularities of the carpal bones and the lower extremities of  the bones of the forearm, the hand in the meantime being slightly moved in various directions to facilitate the process.

277
    The Forearm. - In kneading the forearm (Fig. 48), both hands are used, one grasping the inner, the other the outer, side of the arm, the fingers and thumb of each hand operating together in such a way as to secure thorough, squeezing and manipulation of all the soft parts. The two thumbs should follow the median line of the anterior surface of the forearm. The movement is gradually extended from the wrist to the elbow with a rolling, spiral movement, concluding with special attention to the supinator group at the outer part of the arm just below the elbow.

278
    The Arm. - In masseing the arm (Fig. 49), one hand grasps the extensor group of the back of the arm, while the other manipulates the flexors of the anterior region. In masseing these fleshy parts, it must be borne in mind that the chief purpose of the manipulation is to empty the parts of their blood, and to quicken the circulatory processes by which blood and lymph are conveyed through them. This process may be assisted by grasping the muscles of the anterior and posterior portions of the arm in such a way as to drag the tissues away from the large blood vessels which pass through the arm just beneath the inner border of the biceps muscle (Fig. 16).

279
    The Shoulder. - The deltoid is masséed by seizing it just below the point of the shoulder, the two thumbs grasping the central portion while the fingers work the edges of the muscles. The movement is carried up over the point of the shoulder, and then repeated.

280
    Attention should also be given to the supraspinatus and infraspinatus muscles, and also to the teres muscles, which help to form the posterior boundary of the axilla. The supraspinatus and infraspinatus muscles must be rnasséed by the ball of' the thumb or the ends of the fingers; the teres muscles, by grasping between the thumb and fingers the soft tissues beneath the arm which form the posterior boundary of the axilla, or armpit. It is important that these muscles should not be neglected, as they act an essential part in holding the shoulders back, and are generally weak through neglect to bring them into active use by the maintaining of a proper poise in sitting and standing.

281
    The Foot. - The feet are manipulated (Figs. 50, 51) in essentially the same manner as the hands. The dorsum of the foot and the ankle are masséed with the ends of the fingers ; the tissues of the sole are stretched in the same way as those of the hand. The foot should be rolled by compression of the sides between the two hands in such a manner as to act upon the ligaments and excite activity of the circulation in the deep structures. These manipulations are especially important in cases of flatfoot, or cases in which the instep is low, indicating a tendency to the development of flatfoot.

282
    The foot is finished by grasping the heel in the palm of the hand, rolling and compressing it, and working about it with the ends of the fingers and thumbs.

283
    The Leg. - The leg is manipulated (Fig. 52) in essentially the same manner as the arm, one hand seizing the fleshy mass of the inner and posterior region, the other the outer and anterior, working from the ankle up to the knee. The thumbs should be well worked between the different muscular groups, special attention being given to the peronei muscles at the upper and outer part of the leg, by pressing the tips of the thumbs down between this group and the tibialis anticus. The
tibialis anticus lies in such close relation to the tibia that it is not easy to grasp it between the thumb and fingers, and thus lift it from the bone.. - A similar effect may be obtained, however, by rolling the muscular masses which lie upon the anterior and outer side of the tibia away from the crest of the bone by pressure with the thumbs.

284
    The Thigh. - Grasp the quadriceps with one hand, and with the other grasp the adductor muscles which lie along the inner side of the thigh, working the two groups simultaneously but with alternate movements of the hands.
    Changing hands, grasping the quadriceps with one, and the biceps, or outer hamstring muscles, with the other, a similar manipulation is carried along the outer side of the leg from the knee to the hip.
    Then, grasping the whole limb between the two bands, the  thumbs running along the anterior surface, while the fingers are applied to the posterior region, the whole mass of tissue of the posterior region may be manipulated with the fingers. Care should be taken to drag and stretch the muscles away from the large blood vessels which pass down along, the inner border of the quadriceps.

285
    In manipulating the thigh, unless the patient is very feeble, a considerable amount of force may be employed, as the skin is thick and the mass of tissue great.

286
    The Back (Fig. 53). - The patient should lie upon the face,  with the hands crossed under the forehead. This position secures good separation of the scapulae without rendering the rhomboid muscles too tense to prevent manipulation of the large masses of muscular tissue beneath.

287
    Starting from the base of the skull, work downward, stretching the tissues by pressure of the thumb upon either side of the spinal column, employing the fingers at the same time as much as possible upon the more superficial tissues lying at a distance from the spine. These movements should be made in alternation,. not together, since when made together there is danger of excessive stretching of the skin over the line of spinous processes.

288
    In persons with thick, rigid tissues, manipulation of the back may be performed by the flat surface of the hand pressed firmly upon the tissues, the pressure being increased, if necessary, by reinforcement with the other hand.

289
    After manipulating the large muscular masses of the back from the base of the skull to the sacrum in the manner directed, make deep pressure alongside of the spinous processes with the ends of the fingers, thus crowding the large muscular masses away, and bringing pressure to bear upon the dorsi-spinal veins and upon the ligamentous structures which bind the vertebrae together. Work down first one side of the spine, then the other.

290
    Another manipulation (Fig. 54), which is very effective and should not be forgotten, is a form of digital kneading which consists in placing the ends of the fingers on each side of the spine in such a manner that the fingers are parallel with the spinal column, and then making short but steady and uniform movements to and fro in the direction of the spine, working from above, downward.

291
    Still another valuable form of kneading is executed as follows: Place the two hands, one upon each side of the spine, at the lower part of the back, and work the fingers in such a manner as to make the finger tips creep up the spine in a hitching fashion, dragging the heels of the hands after them. Return by an opposite movement, the heels of the hands leading.

292
    Similar movements may also be executed from the spine outward, following the direction of the ribs. In these movements, the thumbs, the fingers, or the heel of the hand may be the fixed point.

293
    Another form of digital kneading is administered thus: Facing the side of the patient, place the thumbs upon the spine, the fingers reaching over upon the opposite side, the wrists slightly raised. First make firm pressure with the ends of the fingers, then drag the tissues toward the median line. Apply this movement from the occiput to the sacrum and back upon one side, and then treat the opposite side in the same manner.

294
    An effective manipulation of the extensor muscles of the back consists in working the heels of the hands from the sacrum to the base of the skull, then working down, applying the knuckles of the closed hand with a vibratory movement.

295
    Avoid too much pressure over the spinous processes, as it will be likely to injure the skin and produce unpleasant abrasions.  It should be remembered that the skin of the back is much less sensitive than that of other  portions of the body, so. that injury may easily be done without eliciting complaint on the part of the patient.

296
    The Chest. - The tissues of the chest are extremely sensitive, hence care must be taken to avoid bruising them.  This region is masséed by rolling movements effected by the flat of the hand pressed firmly upon the tissues, by intermittent compression, and by ordinary deep kneading with the thumb and fingers, executed with care to avoid pinching.  Much less force should be used upon the chest and abdomen than in masseing the back.  The tissues may be gently dragged away from the median line by the hands placed one on either side, the traction being from the origin toward the insertion of the pectoral muscles.

297
    Many neurasthenic patients present tender points between, the ribs, especially in the axillary line and near the sternum, and also, in some instances, in the region of the heart.  Care must be taken to avoid painful pressure upon these points.

    The Abdomen. - Kneading of the abdomen involves so many special procedures that a particular description will not be given under this head, the subject being more fully dealt with farther on. The same remark applies to kneading of the head, face, neck, and several other special regions.
 

VIBRATION

298
    This procedure consists of fine vibratory, or shaking, movements communicated to the body through the hand of the masseur.  One or both hands may be placed against the surface, or may grasp some part of the patient, as the hand, the foot, or the head.  Sometimes one hand and sometimes both hands are employed.  Vibratory movements may be communicated to the body in a variety of ways.  The following are those which may be most conveniently and efficiently employed : -

299
    Lateral Vibration. - The palmar surface of the hand being held upon the skin with sufficient firmness to prevent slipping, the hand is moved laterally to and fro. The movements should be as rapid as possible -at the rate of at least six to ten per second. It is used chiefly in applications to the head, the joints and the abdomen. The finger tips alone are used for the  head and joints, the palm of the hand in abdominal and pelvic massage.

300
    Knuckle Vibration. - The knuckles of the closed hand are placed in contact with the skin, and moved slowly over the surface , a vigorous vibratory movement being executed at the same time.

301
    Superficial Vibration. - One or both palms being placed upon the surface, they are made to move slowly over the area to be operated upon, a fine trembling movement being executed at the same time. Much practice is required to enable the masseur to execute this movement with sufficient vigor to produce an effect.

302
    Deep Vibration (Fig. 55). - The palm of the hand or the closed fist being placed firmly upon the surface of the part to be acted upon, the, arm is held straight, and a fine jarring or trembling movement communicated to it by an action of the flexor and-extensor  muscles of the upper part of the arm. This movement is difficult to produce, requiring long practice on the part of the operator, and is extremely fatiguing ; but it is one of the most valuable of all the vibratory movements, as by means of it motion can be communicated to the most deeply seated parts.

303
    Shaking (Fig. 56). - The part to be operated upon is grasped firmly by both hands and shaken with a rapid vibratory movement. This movement is especially applicable to the extremities and the head

304
    Digital Vibration  (Fig. 57). - The end of the thumb or of one or more fingers being placed upon the  part to be operated upon, the arm of the operator is thrown into violent vibrations, which are communicated through the thumb or fingers to the patient.
 
305
    Physiological Effects. - The special effect of vibration is that of stimulation.  When applied with sufficient vigor, it is one of the most stimulating of all the procedures of massage.  Deep vibration may be made to act forcibly upon the most deeply situated organs.  The effect of rapid vibration is somewhat similar to that of electricity ; it is capable of causing muscular contraction, even producing tetanus when applied with sufficient vigor.  Very rapid vibration produces a pleasurable, tingling sensation in the parts acted upon, akin to that produced by electricity, but more agreeable, which affords sufficient evidence of the effect of this procedure upon nerve structures.  Under the influence of vibratory movements, the activity of the circulation increases, the blood vessels dilate, the temperature of the part rises, and a pleasurable glow and sensation of well-being pervades the part.

306
     Profound effects may be produced by the application of vibration to nerve trunks and nerve centers, as has been shown by Mortimer Granville, Charcot, and others.

307
    The most pronounced effects of vibration can be obtained only by the aid of proper mechanical appliances, several of which the writer has had in use for a number of years. (Figs. 115-119).

308
    Therapeutic Applications. - Vibration is useful in cases in which stimulation is required, and is only contraindicated in cases in which there is marked hyperaesthesia, acute inflammation, febrile action, morbid growths, or some active morbid process, such as suppuration.  It is valuable in most forms of paresis and paralysis.  As an application to nerve trunks, it is also valuable in neuralgia and neurasthenia and in most functional nerve disorders accompanied by diminished activity.

809
    Applied to the spinal column, it is of special value in sclerosis and other degenerative affections of the spinal cord, as has been well shown by Charcot.  The violent trembling of patients suffering from spinal sclerosis is often greatly relieved.  Vibration of the extremities is one of the most excellent means of relieving coldness arising from spasm of the small vessels due to vasomotor disturbances, numbness, tingling, and various other morbid sensations.
 

PERCUSSION.

310
    This procedure consists of blows administered in various ways and with varying degrees of force. The two hands are used in alternation. The movement is always from the wrist joint, which gives to the blow the quality of elasticity. The inexperienced operator holds the wrist rigid, and pummels the patient much as a pugilist would do, thus producing disagreeable and painful effects. A dexterous and experienced operator maintains a flexibility of the wrist which adds greatly to the
good effects of the treatment.

311
    A stiff blow bruises the surface tissues without producing any beneficial effect upon the deeper structures, the force of the blow being expended upon the surface. An elastic blow, executed in the manner described, penetrates deeply without injuring the superficial structures. A skilled masseur gives springy blows, the movement being almost wholly from the wrist. As a rule, the hand should strike the body transversely with relation to the muscles.

312
    The effect of percussion is increased by placing the muscles upon the stretch. This is accomplished upon the back by having the patient bend forward in a standing or sitting position, and for the abdominal muscles by having the patient raise the head without assistance while lying on the back.
    The following are the principal modes of applying percussion, or clapotement, as this procedure is termed by the French:                                                        

313
    Tapping (Fig. 58). - This is a form of beating in which, the tips of the fingers alone are employed. Either one or all of the fingers of one or both hands may be employed.  It is chiefly used for the head and the chest.

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    Spatting  (Fig. 59). - This consists of percussion with the palmar surface of the extended fingers held rigid.  This .is the form in which percussion is most frequently employed.  It .is applicable to most parts of the body.  It should be used before the application of other procedures when the surface is cold, or when the patient complains of chilly sensations.  It is much used in connection with hydropathic applications as a means of promoting reaction.

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    Clapping  (Fig. 60). - In this procedure, the whole hand is employed, the palmar surface being so shaped as to entrap the air as it comes in contact with the skin, producing a sort of explosive effect and a loud sound.  It is used on fleshy parts when strong surface stimulation is desired.

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    Hacking  (Fig 61). - In this procedure the ulnar, or little finger, border of the hand alone comes in contact with the skin. The fingers are held slightly apart, but loosely, so that they are made to come successively in contact by the force of the blow, thus giving a peculiar vibratory effect.  This form of percussion is exceedingly useful.  It is chiefly employed in applications to the chest, spine, and head.  It may also be employed upon any other part of the body.

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    Beating (Fig. 62). - In this procedure the body is struck by the palmar surface of the half-closed fist, the dorsal surface of the terminal phalanges of the fingers and the heel of the hand alone coming in contact with the body. This mode of percussion is chiefly useful for applications to the lower part of the back and the fleshy portion of the thighs.  It is a powerful means of stimulating the genito-urinary system.  When applied to the sacrum, the patient stands upon the feet bending slightly forward.  Muscle beaters may be very efficiently used for beating (Fig. 136).

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    Reflex  Percussion. - By this term is meant percussion movements to the so-called reflex areas, which have been fully described under the head of "Stroking." The well-known " knee-jerk " is an illustration of the effect of even so gentle a percussion as a, slight tap with the finger tip in provoking reflex action, which, of course, involves the stimulation of one or more nerve centers and nerve trunks, as well as of the acting muscle or muscles.  Percussion of any part of the body  doubtless gives rise to reflex activities of varying degree, but the most pronounced effects necessarily follow the application of this procedure to those surfaces which are in most direct relation to definite centers in the spinal cord.
    The principal reflex areas which may be named, and the proper mode of stimulation, are as follows: 

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    Interscapular Area. - The application is best made with the patient sitting with the arms folded in front, and bending slightly forward. The masseur, standing behind, applies percussion-hacking and spatting-to the space between the scapulae, or shoulder blades. The interscapular reflex has relation to the sixth, seventh, and eighth cervical, and first dorsal, segments of the spinal cord.

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    Epigastric Area. - The patient lying upon the back, tapping, hacking, spatting, or beating movements are applied to the sides of the chest between the fourth and sixth ribs. This area is in relation to the fifth, sixth, and seventh dorsal segments.

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    Abdominal Area. - With the patient lying upon the back, tapping, hacking, spatting, or clapping movements are applied to the sides of the abdomen in the mammary line. This application stimulates the eighth, ninth, tenth, eleventh, and twelfth dorsal segments.

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    Oremasteric Area. - Hacking and percussion of the inner portion of the upper half of the thigh stimulates the first, second, and third lumbar segments.

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    Gluteal Area. - With the patient lying upon the face, hacking, spatting, clapping, or beating movements are applied to the fleshy portions of the hips, thereby stimulating the fourth and fifth lumbar centers.

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    Plantar Area. - Spatting and backing movements applied to the sole of the foot stimulate the five sacral segments of the cord.                                     I

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    Tendon Reflexes. - Percussion, of the tendon of a muscle, and sometimes percussion of the muscle itself  gives rise to muscular contraction.  This is best illustrated in the knee in what is called the "knee-jerk," or "Patellar reflex." With one limb crossed over the other, a light tap upon the tendon just below the patella gives rise in most persons to contraction of the quadriceps extensor, as evidenced by a movement of the foot.  To be effective, it is necessary that the blow should be applied when the tendon of the muscle is tense.

    The principal points at which tendon percussion may be advantageously employed, and the nerve centers which are stimulated at the several points named, are as follows: 

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    Back of the Neck. - With the patient sitting with the head flexed forward as far as possible, apply hacking movements from the vertebra prominens to the occiput, striking the muscles transversely.  This application stimulates the first, second, third, and fourth cervical segments.

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    Wrist Tendons. - Grasping the patient's hand with the palmar surface up, and extending it as far as possible, so as to render tense the tendons at the wrist, make light tapping or hacking movements across the front of the wrist.  In many cases a decided muscular contraction may be noticed after each blow.  Percussion at this point stimulates the fourth, fifth, sixth, seventh, and eighth cervical segments of the cord.

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    The “Kneejerk" (Fig. 63).- The patient sits with one leg crossed over the other, so as to render tense the tendon of the extensor muscles of the thigh. Tapping the part of the tendon just below the patella with the tip of the middle finger, or applying a transverse blow with the edge of the hand, will usually give rise to strong contraction of the quadriceps and thrusting of the toe forward.  In some persons this reflex may be developed with the patient lying with the limbs extended, by placing one finger just above the patella and crowding it down as far as possible, then striking the finger, with the middle finger of the other hand.  This reflex involves all five of the lumbar segments of the cord.

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    The Ankle Reflex. - With the patient lying upon his face,  the limbs extended, grasp the foot with one hand and forcibly  flex it upon the leg so as to render the tendon Achilles as tense as possible. Tapping or hacking movements applied to the stretched tendon will often give rise to contraction of the muscles of the calf and extension of the foot. This application  stimulates the first, second, and third sacral segments.

330
    The tendon reflexes are all rendered more active by diverting the patient's attention. This may best be accomplished by causing him to contract forcibly a muscular group in some other  part of the body than that which it is desired to operate upon. For example, in testing the ankle and knee reflexes, the patient  may be caused to close his hands as firmly as possible; when operating upon the wrist or the back of the neck, the patient  may be made to forcibly flex or extend his foot.

331
    Percussion is sometimes applied by means of rubber balls  attached to reed or whalebone rods, or by elastic rubber tubes attached to a handle, the so-called “muscle beater"of  Klemm. These instruments are worthy of mention, as they  afford a means by which the patient can apply percussion to himself (Fig 138).

332
    Point Percussion. - Percussion applied at the motor  points is sometimes a most effective means of producing muscular con traction, as at these points the motor nerves may be directly stimulated by the mechanical force applied. Tapping and hacking are the most efficient means of applying point percussion. Usually the best effect will be obtained by placing one finger upon the motor point, pressing firmly upon the nerve, and then tapping the finger with the fingers of the other hand.

333
    Physiological Effects. - Percussion is a powerful excitant, acting -not only upon the skin, but upon the tissues beneath. A short, light application produces spasm of the  superficial vessels, which may be easily demonstrated by tapping a point upon the back of the hand with the finger for a few seconds, and noting the decided pallor which results. Strong percussion, or a prolonged application of light blows,  gives rise to dilatation of the surface vessels, as evidenced by  marked redness of the skin. Strong percussion may even produce paralysis of the blood vessels.

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    Reflex percussion is certainly a most powerful means of  stimulating those nerve centers which may be brought under the  influence of this special mode of application, which include, to  a greater or less extent, all the segments of the cord. The lumbar and sacral portions of the cord especially may be acted  upon in a powerful manner by this procedure. The therapeutic value of this special form of percussion will be recognized at once when it is remembered that the important functions of the bladder, rectum, and sexual organs are largely controlled by centers located in the lower portion of the cord.

335
    The direct application of percussion to the spine is one of the most powerful means of stimulating the vasomotor centers and the nutritive functions of the viscera which are controlled by the splanchnics. The cervical splanchnics which emanate from that portion of the spine included between the first cervical and the fourth dorsal segments, control the circulation of the heart, stomach, and lungs ; the second group of splanchnics, leaving the cord between the second dorsal and the second, lumbar, controls the great vascular area of the intestines; while the third set of splanchnics, leaving the cord at the second, and third sacral segments, controls the circulation and, through it, the nutrition and, to a large extent, the functions of the genital organs.

336
    It is thus apparent that vigorous vibratory movements  communicated to the spine, especially by means of hacking and beating, which act most effectively upon deep-seated structures, may be the means of powerfully influencing the functions of all the viscera of the trunk, as well as the genital organs, though the latter are partly internal and partly external.

337
    Point percussion produces powerful motor effects, inducing vigorous contraction of the muscles to which the nerve operated upon is distributed, The results produced by point percussion are often more marked than those obtained from faradization. especially in cases in which the excitability of the muscle is modified by disease.

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    Therapeutic Applications. - Percussion, especially spatting and clapping, is much used in connection with hydrotherapy as a means of promoting reaction after cold applications to the surface.  This procedure is useful in all cases in which stimulation of the skin is desirable, either for derivative effects or for direct influence upon the skin.  It is consequently useful in all cases of functional inactivity of the skin, as in jaundice.

339
    In chronic sciatica, lumbago, and coldness of the extremities, percussion has a decidedly favorable influence, as also in passive congestion of the liver and spleen, in which cases it is employed over the region of these organs.  In constipation, it may be applied over the abdomen as a means of stimulating general peristaltic activity, and over the sacrum to stimulate activity of the lower bowel.

340
    Beating the sacrum is valuable in atony of the bladder and in impotence or sterility from loss of sexual vigor.  The ancient Romans practiced whipping of the buttocks for relief of impotence in man and sterility in women.  Vigorous spanking has sometimes been employed by libertines for the same purpose; and the writer has met one or two cases in which whipping had given rise, to involuntary action of the genital organs in a boy, and one or two cases in. men in which the same effect was produced by percussion of the lower portion of the back and upper thighs, thus clearly demonstrating the powerful influence of this procedure upon the centers of the cord.

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    Hacking of the spine is especially useful in sclerosis; and hacking of the chest, in unresolved pneumonia, adhesions from chronic pleurisy, and in promoting absorption in cases of serous effusion into the pleural cavity.