Chapter 6. Massage

________________________________________________
_ CHAPTER VI. MASSAGE

How to deprive rest of its evils is the title with which I might very well have labelled this chapter. I have pointed out what I mean by rest, how it hurts, and how it seems to help; and, as I believe that it is useful in most cases only if employed in conjunction with other means, the study of these becomes of the first importance.

The two aids which by degrees I learned to call upon with confidence to enable me to use rest without doing harm are massage and electricity. We have first to deal with massage, and I give some care to the description of details, because even now it is imperfectly understood in this country, and because I wish to emphasize some facts about it which are not well known, I think, on either side of the Atlantic.

Massage in some form has long been in use in the East, and is well known as the _lommi-lommi_ of the slothful inhabitants of the Sandwich Islands. In Japan it is reserved as an occupation for the blind, whose delicate sense of feeling might, I should think, very well fit them for this task. It is, however, in these countries less used in disease than as the luxury of the rich; nor can I find in the few books on the subject that it has been resorted to habitually as a tonic in Europe, or otherwise than as a means of treating local disorders.

It is many years since I first saw in this city general massage used by a charlatan in a case of progressive paralysis. The temporary results he obtained were so remarkable that I began soon after to employ it in locomotor ataxia, in which it sometimes proved of signal value, and in other forms of spinal and local disease. At first I had to train nurses to use it, but I soon found that, although it was of some service to their patients, no one could use massage well who was not continually engaged in doing it. Some men do it better than any woman; but I prefer, nevertheless, for obvious reasons, to reserve men for male patients, except that in cases where _strength_ is of moment, as in the forced movements and the very hard rubbing needed for old articular adhesions, in which force must be exercised without violence, it is usually impossible to secure the necessary power in a feminine manipulator.

A few years later I resorted to it in the first cases which I treated by rest, and I very soon found that I had in it an agent little understood and of singular utility.

It will be necessary, in pursuance of my plan, to describe as minutely as the limits of a chapter will allow how and why this means is employed. The process and order of what is known to the manipulator as "general massage" follows.

After three or four days in bed have somewhat accustomed the patient to the general routine of treatment, a masseur or masseuse is set to work. If any special care is needed,--the avoidance of manipulating one part or added attention to another, tender handling of a sensitive or timid patient,--these matters have been ordered in advance by the physician. An hour midway between meals is chosen, and, the patient lying in bed between blankets, the manipulator begins, usually with the feet. A few rapid rubs of the whole foot and leg are given to start with; then the leg, except the foot and ankle, is covered up, and the operation commences upon the foot, of which the skin is picked up and rolled between the fingers, the whole foot receiving careful attention,--the toes are pulled, bent, and moved in every direction, the inter-osseous groups worked over with the thumbs and fingers or finger-tips, the larger muscles and subcutaneous tissues squeezed and kneaded, and last the whole mass of the foot rolled and pressed against the bones with both hands. A few rapid upward strokings with some force complete the treatment of the part, and the ankle is next dealt with. The joint is moved in every possible direction, slowly but firmly, the crevices between the articulating bones sought out and kneaded with the finger-tips, and the foot and ankle are then carefully covered. After the same rapid stroking upward of the leg with which it began has been repeated for the sake of the slight stimulation of the skin-vessels and nerves, the muscles of the leg are treated, first by friction of the more superficially placed masses, then by careful deep kneading (_petrissage_) of the large muscles of the calf, twisting, pressing, and rolling them about the bone with one hand while the other supports the limb. In fat or heavily-muscled subjects it may be necessary to use both hands to get sufficient grasp of the muscles. The tibialis anticus and muscles of the outer side of the leg are operated upon by rolling them under the finger-tips and by pressing with the thumb while firmly pushing upward from the ankle to the knee. At brief intervals the manipulator seizes the limb in both hands and lightly runs the grasp upward, so as to favor the flow of the venous blood-currents, and then returns to the kneading of the muscles,--and each part is finished by light yet firm upward stroking, the hand returning downward more lightly, yet without breaking its contact with the skin.

Care must be taken as the different groups of muscles are treated that the leg is placed in the position which will most completely relax the ones to be operated upon. Any tension of muscles wholly defeats the effort of the masseur.

After completing the process upon both legs, the arm is next treated in the same manner, the hand receiving somewhat more detailed attention than the foot. Pains must be taken to reach the several groups of the forearm by operating from both sides of the arm. The ordinary manipulation of the shoulder can be accomplished with the patient lying down; but if special conditions, such as articular stiffening, call for unusual care or unusual force, it will be found best to treat the shoulder with the patient seated. The treatment of the arms is concluded with upward stroking (_effleurage_), as with the leg.

In the order usually pursued, the back is the next region treated. The patient lies prone, folding the arms under the head; a firm pillow is put under the epigastric region, so as to the better relax the back muscles, which are too tense when a person lies flat. Beginning from the occiput, both hands stroke firmly and rapidly downward and outward to the spines of the scapulae, at first lightly, then with increasing force. Then the whole back is vigorously rubbed--scrubbed one might call it--with up-and-down strokes, as a preliminary application. The erector spinae masses are treated by careful finger-tip kneading. Working from the spine outward to the axillary line, the muscles of the ribs are acted upon with flat-hand rubbing. The groups of the upper back and shoulder-blades are kneaded and squeezed, the arms being partly abducted so as to separate the shoulder-blades and allow the operator to reach the muscles underlying them. The lumbar regions receive their manipulation last. If it is desirable to give special attention or an extra share of manipulation to any part of the spinal region, this is done as the physician may have ordered, and the whole process is completed by downward friction over the spine, given vigorously and as rapidly as possible.

The chest is the next region to be handled, the patient turning from the prone to the supine position. In women the breasts are usually best left untouched unless special conditions demand their treatment.

The last and perhaps most important part of the process of general massage is the rubbing of the abdomen. Particular care is needed to secure complete relaxation, as nervous patients and, still more, hysterical patients are apt to present extreme rigidity of the abdominal muscles. The head is raised by pillows, the knees are slightly flexed and sometimes supported by a folded pillow also. With this position the rigidity generally yields to gentle persistence, at any rate after a few treatments. If it does not do so, a lateral decubitus may be tried, a position in which the intestinal regions may be very thoroughly treated, and in which, if there be gastric dilatation, the stomach-walls can be best reached. Sweeping circular frictions about the navel as a centre begin the process; the abdominal walls are then kneaded and pinched[16] with one or both hands; deep, firm kneading of the whole belly with the heel of the hand follows, the movements following the course of the colon. Next, the fingers of one hand are all held together in a pyramidal fashion and thrust firmly and slowly into the abdomen, in ordinary cases both hands being used thus alternately, in fat or resisting abdomens one hand pressing upon and aiding the other, and travelling thus over the ascending, transverse, and descending colon. To conclude, the whole belly is shaken by a rapid vibratory motion of the hands (to which is sometimes added succussion by slapping with the flat or cupped hand), and the whole process ends with quick, circular rubbing of the surface.

[Footnote 16: "Pinch" is used to avoid the use of a technical term, but should be understood to mean the grasping and squeezing of a part with the whole hand, using the palmar portion of the fingers to press the grasped mass against the "heel" of the hand. Fuller technical details of the massage process and consideration of its effects will be found in the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham, Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's "System of Medicine" (1896), by Dr. John K. Mitchell.]

In cases of troublesome constipation or where other special indications exist, treatment of the abdomen may be much extended beyond the limits here suggested, and indeed it must be remembered that the process of "general massage" as described is capable of a great variety of useful modification to meet individual needs, and is so modified daily by the careful physician and the watchful masseur. It would not be possible or desirable here to describe all the movements which a skilful rubber makes in his treatment, and I have only attempted a skeleton-statement. It will perhaps be noticed by those familiar with the technique of massage that nothing is here said about the use of the movements classed under the general head of "tapotement," the tapping and slapping motions. They have no proper place in the treatment of cases of nervousness, and usually will serve only to irritate and annoy the patient, and often greatly to increase the nervous excitement. Their routine use or over-use constitutes one of the defects of the system of massage as usually practised by the Swedish operators; and when patients tell me, as many do, that "they cannot stand massage," it is often found that the performance of a great deal of this useless and fretting manipulation has constituted a great part of the treatment, and that deep, thorough, quiet kneading can be perfectly borne.

A few precautions are necessary to observe. The grasping hand should carry the skin with it, not slip over the skin, as the drag thus put upon the hairs will, if daily repeated, cause troublesome boils. The use of a lubricant avoids this, and is a favorite device of unskilful manipulators. It also does away with much of the good effected by skin-friction, is uncleanly, very annoying to many patients, promotes an unsightly growth of hair, and should be avoided except where it is desired to rub into the system some oleaginous material. There are exceptional cases where a very dry, harsh skin or a tendency to excessive sweating during massage makes the use of some unguent desirable. Cocoa-oil may be used, or what is perhaps more agreeable, lanolin softened to the consistency of very thick cream by the addition of oil of sweet almonds. As little as possible should be made to serve.

Too much care cannot be used to cover with stockings and warm wraps the parts after in turn they have been subjected to massage. As to time, at first the massage should last half an hour, but should be increased in a week to a full hour. I observe that Dr. Playfair has it used twice a day or more, and I have since had it so employed in some cases, letting the masseuse come before noon, and allowing the nurse to use it at night if it does not interfere with sleep, which is a matter to be tested solely by experiment. Commonly, one hour once daily suffices. I was at one time in the habit of suspending the use of both massage and electricity during menstruation, because I found occasionally that these agents disturbed or checked the normal flow. Of late, however, I continue to employ both agents, but confine them to the limbs. I have met with rare cases in which almost any massage gave rise to a uterine hemorrhage, and in which the utmost caution became necessary.

Women who have a sensitive abdominal surface or ovarian tenderness have of course to be handled with care, but in a few days a practised rubber will by degrees intrude upon the tender regions, and will end by kneading them with all desirable force. The same remarks apply to the spine when it is hurt by a touch; and it is very rare indeed to find persons whose irritable spots cannot at last be rubbed and kneaded to their permanent profit.

Sometimes when the patient is found to be much exhausted by massage, it is well to give some stimulating concentrated food afterwards; occasionally it may be necessary both before and after. In this case it would be well to see that the rubbing was not being made too severe.

Very rarely I find a patient to whom all massage is so disagreeable or produces such annoying nervousness as to make manipulation impossible; sometimes, though very rarely, massage, especially frictional movements, causes sexual excitement when applied in the neighborhood of the genital organs, or even on the buttocks and lower spine, and this may occur in either sane or insane patients: if the rubber observe any signs of this, it will of course be best to avoid handling the areas which are thus sensitive.

Another complaint sometimes made is of chilliness after treatment, and especially of cold feet. If this is not lessened after a few days, the lower extremities may be rubbed last instead of first, or as is now and then useful, the whole order of massage may be changed so as to begin with the abdomen, chest, and upper extremities and conclude with the back and legs.[17]

[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends this order.]

Beginning with half an hour and gradually increasing to about an hour (a little more for very large or very fat people,--a little less for the small or thin) the daily massage is kept up through at least six weeks, and then if everything seems to be going along well, I direct the rubber or nurse to spend half of the hour in exercising the limbs as a preparation for walking. This is done after the Swedish plan, by making very slowly passive and extreme extensions and flexions of the limbs for a few days, then assisted movements, next active unassisted movements, and last active movements gently resisted by nurse or masseuse. When the patient is able to sit and stand, it is well to keep up and extend the number of these gentle gymnastic acts and to encourage the patient to make them habitual, or at least to keep them up for many months after the conclusion of treatment.[18]

[Footnote 18: Some care is needed not to overwork patients. For details I must refer to manuals of Swedish Gymnastics.]

At the seventh week massage is used on alternate days, and is commonly laid aside when the patient gets up and begins to move about.

In 1877, several of the members of the staff of the Infirmary for Nervous Disease, and especially my colleague, Dr. Wharton Sinkler, obliged me by studying with care the influence of massage on temperature, and some very interesting results were obtained. In general, when a highly hysterical person is rubbed, the legs are apt to grow cold under the stimulation, and if this continues to be complained of it is no very good omen of the ultimate success of the treatment. But usually in a few days a change takes place, and the limbs all grow warm when kneaded, as happens in most people from the beginning of the treatment.[19] The extremely low temperature of the limbs of children suffering with so-called essential paralysis is well known. I have frequently seen these strangely cold parts rise, under an hour's massage, six to ten degrees F. In such small limbs, the long contact of a warm hand may account for at least a part of this notable rise in temperature. In adults this can hardly be looked upon as a cause of the rise of temperature produced by massage, first, because the long exposure of large surfaces incident to the process is calculated to lessen whatever increase of heat the contact of the hand may cause, and secondly, because this rise is a very variable quantity, and because occasionally some other and less comprehensible factors actually induce a fall rather than a rise in the thermometer as a result of massage.

[Footnote 19: See also page 91.]

In very nervous or hysterical women, ignorant of what the act of kneading may be expected to bring about, and especially in such as are thin and anaemic and have either a somewhat high or an unusually low normal temperature, we may find at first a slight fall of the thermometer, then a fairly constant rise, with some irregularities, and at last, as the health improves, a lessening effect or none at all.

The most notable rise is to be found in persons who, owing to some organic disease, have acquired liability to great changes of temperature.

It is impossible to observe the increase of heat which follows both massage and electricity without inferring that these agents must for a time, like exercise and other tonics, increase the tissue-waste by the stimulus they cause of the general and interstitial circulations, and by the direct influence they seem to have on the tissues themselves. I have sought to study this matter carefully by placing patients on a fixed and competent diet of milk alone, and by estimating the waste of tissues as shown in the secretions before and after the use of massage. This study, although it was never completed in a satisfactory manner, would seem to show that massage does not much alter the total elimination of the entire day, but causes a large and abrupt increase within three hours, followed by a compensatory decline.[20]

[Footnote 20: A number of observations in late years have been made upon the effect of massage upon elimination. Among the articles to which the practitioner desiring further to study this subject may be referred are,--

_Edin. Clin. and Path. Jour_., Aug., 1884.

_Jour, of Physiol._, vol. xxii., p. 68.

_Centralbl. f. Inner. Med._, 1894, No. 40, p. 944.

_Munch. Med. Woch._, April 11 and April 18, 1899 (Influence of bodily exercise upon temperature in health and disease).

Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque and Marette, and Maggiora.]

I add a number of tables, which very well illustrate the facts above stated as to rise of temperature.

Mrs. J., at rest, on the usual diet. Manipulation at 11, daily:

Before Massage.  After Massage.
100                 100
100                 100-1/5
99-2/5              99-4/5
99-4/5              100
99-2/5              100
100                 100
99-4/5              100
99-4/5              100
Miss P., aet. 24, hysteria:
Before Massage.  After Massage.
99-1/4              99-1/4
98-1/4              99
98-1/2              99
98-1/4              99
98-1/4              98-1/4
99                  99-3/4
100-1/5             100-2/5
100-2/5             101-2/5
100-2/5             100-3/5
100-3/5             100

Mrs. L., a very thin, feeble, and bloodless woman, aet. 29 years:

Before Massage. After Massage.

 
99               100
98-1/2           99-1/5
98               98-2/5
99               100
98-2/5           98-4/5
99               99-4/5
100              100-1/5
99               99-4/5

Mrs. P., aet. 31, feeble and anaemic, nervous, slight albuminuria and chronic bronchitis. Liable to fever. 3 P.M.:

  
Before Massage.  After Massage.
101-3/5           102
100               100-4/5
99                99-4/5
100               101
99-2/5            100-1/5
99-4/5            100-3/5
100-3/5           101-3/5
100-2/5           99-4/5
100-3/5           100-2/5
100-3/10          100-9/10
99-1/5            99-4/5

These temperatures were taken always before 4 P.M., and at intervals of three days. Her morning temperature was usually 99 deg. to 99-4/5 deg., and in the evening, 9 to 10 o'clock, it always rose to 100 deg., 101 deg., and at times to 102 deg..

As I have said already, there are persons who, under circumstances seemingly alike, have from massage a large rise of temperature, and others who experience none. I give a single case of what is rare but not exceptional,--an almost constant fall of temperature.

Miss N., aet. 21, hysteria, good condition:

Before Massage.     After Massage.
     98                97-3/5
     98-1/2            98-1/2
     98                98
     98-2/5            98
     98-4/5            98

These facts are, of course, extremely interesting; but it is well to add that the success of the treatment is not indicated in any constant way by the thermal changes, which are neither so steady nor so remarkable as those caused by electricity.

If now we ask ourselves why massage does good in cases of absolute rest, the answer--at least a partial answer--is not difficult. The secretions of the skin are stimulated by the treatment of that tissue, and it is visibly flushed, as it ought to be, from time to time, by ordinary active exercise. Under massage the flabby muscles acquire a certain firmness, which at first lasts only for a few minutes, but which after a time is more enduring and ends by becoming permanent. The firm grasp of the manipulator's hand stimulates the muscle, and, if sudden, may cause it to contract sensibly, which, however, is not usually desirable or agreeable. The muscles are by these means exercised without the use of volitional exertion or the aid of the nervous centres, and at the same time the alternate grasp and relaxation of the manipulator's hands squeezes out the blood and allows it to flow back anew, thus healthfully exciting the vessels and increasing mechanically the flow of blood to the tissues which they feed. It is possible also that a real increase in the production of red corpuscles is brought about by repeated applications of massage, as will be seen later on.

The visible results as regards the surface-circulation are sufficiently obvious, and most remarkably so in persons who, besides being anaemic and thin, have been long unused to exercise. After a few treatments the nails become pink, the veins show where before none were to be seen, the larger vessels grow fuller, and the whole tint of the body changes for the better.

In like manner the sore places which previously existed, or which were brought into sensitive prominence by the manipulation, by degrees cease to be felt, and a general sensation of comfort and ease follows the later treatments.

Although this plan of acting on the muscles seems to dispense with any demands upon the centres, it is not to be supposed that it is altogether without influence on these parts. In fact, extreme use of massage occasionally flushes the face and causes sense of fulness in the head or ache in the back. The actual large increase in the number of corpuscles in the circulation brought about by massage may be one of the reasons for this. We have added, perhaps, millions of cells to the number in the vessels in a very short time, and need not be astonished if some signs of plethora follow. Moreover, in some spinal maladies it has effects not to be altogether explained by its mechanical stimulation of the muscles, nerves, and skin.

That the deep circulation shares in the changes which are so obvious in the superficial vessels has been shown by various observers of experimental and clinical facts. Firm deep muscle-kneading of the general surface will almost always slow and strengthen the pulse. If the abdomen alone is thoroughly rubbed the same effect appears in the pulse, but less in degree, and massage of the abdomen has also a distinct effect in increasing the flow of urine, a fact worth remembering in cases of heart-disease. In a case of albuminuria from exercise, W.W. Keen has shown that massage did not cause the return of the albumin after rest, though exercise did, a difference due to the opposite effects upon blood-pressure of the two forms of activity. Lauder-Brunton has shown that more blood passes through a masseed part after treatment. Dr. Eccles and Dr. Douglas Graham both found a decided decrease in the circumference of a limb after massage, showing how completely the veins must have been emptied, for the time at least,--an emptying which would surely be followed by an increased flow of arterial blood into the treated region. Dr. J.K. Mitchell, in 1894,[21] made a large number of examinations of the blood before and after massage, some in patients under treatment for a variety of disorders affecting the integrity of the blood, and a few in perfectly healthy men. With scarcely an exception there was a large increase in the number of corpuscles in a cubic millimetre, and an increase, though of less extent, in the haemoglobin-content. Studies made at various intervals after treatment showed that the increase was greatest at the end of about an hour, after which it slowly decreased again; but this decrease was postponed longer and longer when the manipulation was continued regularly as a daily measure.[22] The author's conclusions from these examinations were interesting, and I quote them somewhat fully. The fact that the haemoglobin is less decidedly increased than the corpuscular elements makes it seem at least probable that what happens is, that in all the conditions in which anaemia is a feature there are globules which are not doing their duty, but which are called out by the necessities of increased circulatory activity brought about by massage. If this is the first effect, yet as it is observed that the increase of corpuscles, at first passing, soon becomes permanent, we must conclude that massage has the ultimate effect of stimulating the production of red corpuscles.

[Footnote 21: American Journal of the Medical Sciences, May, 1894.]

[Footnote 22: Numerous examinations made since have quite uniformly agreed with the former remarkably constant results.]

One sometimes hears doubts expressed whether a patient with a high-grade anaemia is not "too feeble for such strong treatment" as massage. This study of one of the ways in which massage affects such cases may fairly be taken as proof of the certainty and safety of its effect on them, provided always it be done properly and with intelligence. Some check upon this may be had, as is said elsewhere, by the general effect upon the patient. It may be repeated that the pulse should be slower and stronger after an hour of deep massage, and that this effect will not be produced by superficial rubbing (indeed, with light or too rapid manipulation the pulse may become both less strong and more rapid), and finally the flow of urine should be increased. With these easily observed facts to aid, it may readily be judged whether massage is being rightly applied or not without the need of a visit from the physician during the hour of treatment. A final test might readily be made by examination of the blood and counting the red corpuscles before and after treatment. No doubt in very bad cases a small increase or none would be found at first, but a week of daily manipulation should show a distinct addition to the blood count. A striking instance in which this examination was repeatedly made is related on p. 184.

"It is evident that our present definitions of anaemia are insufficient. An essential part of the description in all of them is that there are defects of number, of color, or of both in the blood. This is not necessarily or always true. The fault may lie in a lack of activity or of availability in the corpuscles. The state of things in the system may be like the want of circulating money during times of panic, when gold is hoarded and not made use of, and interference with commerce and manufactures results.

"Neither an anaemic appearance nor a blood-count is alone enough for a certain diagnosis. Other signs must be used as a check on the blood examination for the establishment of the existence of anaemia. For instance, many cases here recorded had full normal or even supra-normal corpuscle-count, with a good percentage of haemoglobin. Yet they presented every external sign of poverty of blood: pallor of skin and, more important still, of mucous membranes, cold extremities, anorexia, indigestion, dyspnoea on trifling exertion. In such cases we must suppose either that the total volume of the blood is reduced, or that the usefulness of the corpuscles is in some way impaired, or that both these troubles exist together."[23]

[Footnote 23: J.K. Mitchell, _loc. cit._]

I have said above that the face was not touched in the course of the rubbing. There are cases, however, in which massage of the head and face may be usefully practised. Some obstinate neuralgias are helped by it temporarily, and very often it is of use with other means to aid in a permanent cure. Many headaches of a passing character may be dissipated promptly by careful massage of the head or by downward stroking over the jugular veins at the sides of the neck to lessen the flow of blood into the cerebral vessels, where the pain is due to congestion or distention, and careful manipulation of the facial muscles in paralysis is of service in restoring loss of tone and improving their nutrition. It is worth adding here, as women patients frequently say that during their illness the hair has become thin or shown a great tendency to fall, that daily firm finger-tip massage of the head for ten or twelve minutes, followed by rubbing into the scalp of a small amount of a tonic, either a bland oil or if need be of some more stimulating material, will in a great majority of the instances where loss of hair is due to general ill-health perfectly restore its vigor and even its color.

I am accustomed to pay a good deal of attention to the observations made on these and other points by practised manipulators, and I find that their daily familiarity with every detail of the color, warmth, and firmness of the tissues is of great use to me.

A great deal of nonsense is talked and written as to the use and the usefulness of massage. The "professional rubber" not unnaturally makes a mystery of it, and patients talk foolishly about "magnetism" and "electricity;" but what is needed is a strong, warm, soft hand, directed by ordinary intelligence and instructed by practice; and this is the whole of the matter, except in the massage of such obscure conditions as need full knowledge of the anatomical relations and physiological functions of the parts to be rubbed. It is a fact that I have known country physicians who, desiring to use massage and not having a practitioner of it within reach, have themselves trained persons to do it, with considerable resultant success.

It is not, perhaps, putting it too strongly to say that bad massage is better than none in those cases in which manipulation is needed. Very little harm can result from its use even by unskilled hands, provided that reasonable intelligence direct them. _

Read next: Chapter 7. Electricity

Read previous: Chapter 5. Rest

Table of content of Fat and Blood: Treatment of Certain Forms of Neurasthenia and Hysteria


GO TO TOP OF SCREEN

Post your review
Your review will be placed after the table of content of this book