The Art of Massage
J. H. Kellogg, M.D.
THE PROCEDURES OF MASSAGE.
All the different useful procedures in massage may
be classified under seven heads, as follows:
7. Joint Movements.
Under each of these heads we have several subdivisions,
which must be separately considered.
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.
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 :
(1) Elevation of the temperature of a part by the
communication of animal heat.
(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.
(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).
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.
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
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.
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.
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.
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.
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
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.
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).
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
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
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.”
There are several forms of stroking:
1. With the finger tips, digital stroking.
2. With the palm of one or both bands, palmar
3. With the knuckles, knuckle stroking.
4. Reflex stroking.
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
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.
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
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
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.
The various reflexes are named partly from their
location and partly from the muscular effects produced reflexly by their
stimulation, as follows:
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.
Plantar (causes contraction of the muscles
of the thigh).
A seventh may be termed the axillary.
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.
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.
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
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
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.
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
branches to the muscles involved in these reflexes, also send branches
to internal parts.
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.
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.
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.
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.
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.
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.
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
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.
Centrifugal friction, in which the movement
is opposite to that of the blood current.
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.
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
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.
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.
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.
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).
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).
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).
Friction is applied to the following parts in the
Head, from before backward, and above downward.
Back, above shoulder blades, circular, from
shoulder blades to sacrum, down; in the region of the loins, from the sides
toward the spine.
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.
To promote absorption, rub toward the heart
For sedative and derivative effects upon
the viscera and nerve centers, rub downward (centrifugal friction).
Rubbing upward, or in the direction of the venous
blood current, increases the activity of the circulation.
Rubbing downward decreases vascular activity.
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.
As a rule, some lubricant should be used. Fine vaseline,
cocoanut oil, cacao butter, and talcum powder are the best lubricants.
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
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.
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:
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
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.
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
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.
The Arm. - Work the arm in a manner similar
to that described for the forearm.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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
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.
Physiological Effects. - The physiological
effects of 'riction are somewhat complex. They may be briefly stated
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.
Reflex or stimulating effects may be increased
by using no lubricant of any kind - in other words, making friction upon
the dry skin.
Mechanical effects are increased, and the
reflex or irritant effects decreased, by lubrication of the skin.
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.
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.
Therapeutic Applications. - Friction is usually
employed therapeutically in conjunction with kneading and other movements,
being used in alternation with other procedures.
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.
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.
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.
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.
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
In cerebral congestion the rubbing should
always be downward. In anaemia of the brain, rub upward.
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.
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.
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.
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.
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."
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
Rolling is especially useful in masseing the upper
portion of the back, the hips, arms, and legs.
Wringing (Fig.44). - This procedure is executed
by grasping the limb with the two hands placed on opposite sides and close
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.
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.
The movements must not be too rapid; the rate should
not exceed thirty per minute.
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
blood vessels and nerves. When employed for the scalp, either
one or both hands may be used.
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.
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.
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.
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
Kneading acts more powerfully than any other procedure
in massage, in stimulating heat production.
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.
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.
Mode of Applying Kneading to Different Parts.
Begin either with the hands or the feet. If with the hands, proceed
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).
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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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 : -
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.
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
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.
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.
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
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
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.
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.
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).
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.
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.
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.
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.
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:
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.
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.
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.
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.
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).
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:
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.
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.
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.
Oremasteric Area. - Hacking and percussion
of the inner portion of the upper half of the thigh stimulates the first,
second, and third lumbar segments.
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.
Plantar Area. - Spatting and backing movements
applied to the sole of the foot stimulate the five sacral segments of the
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:
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
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.
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
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.
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.
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).
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
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.
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.
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.
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
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.
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.
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.
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.
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.