NLM QDlOlbl?  M
/£/-/- /
SURGEON GENERAL'S OFFICE

    LIBRARY.
Section.
 „„.„*,   No. % 2.f.Af^-
r.D.S.G.O.         '        3_5i3
NLM001016974 
 
Fig. 7.  Ettleurage.  Used upon larger parts. 
 
Fig. 4.  Kneading motion for skeletal muscles.  Used upon
                 larger parts,  nil —14. 
 
Fig. 3.
I.  Kneading motion for skeletal muscles.  Used upon
              the smaller parts. 
MASSAGE
A PRIMER FOR NURSES
SARAH E. POST, M.D.
LECTURES BEFORE THE TRAINING SCHOOLS FOR NURSES. CONNECTED WITH BELLEVUE HOSPITAL,
  MT. SINAI HOSPITAL, ST. LUKE'S HOSPITAL AND CHARITY HOSPITAL, NEW YORK.
    SECOND EDITION

WITH SEVEN ORIGINAL PHOTO-PLATES
      NEW YORK
THE NIGHTINGALE PUBLISHING OO.
     13 WEST 42D STREET
       l8t)I
*
%3ffl+)t) 
W6£
F857m
 1891
      Copyright
         by
The Nightingale Publishing Co. 
CONTENTS.
I. £" Motions of Massage,5
II.  General  Massage,
III. Local  Massage, .
      Massage of the  Head,
          Neck, .     :
          Breast,
          Abdomen,  .
          Pelvis,
          Coccyx,
          Limbs,
          Eye,   .
      Systemic Results of Massage,
PAGE
  12
  18

  29
  5°
  38
  40
  43
  44
  44
  45
  45
  ♦The term Petrissage is omitted in these pages because not used by the
physicians of our city in their directions to nurses, all kneading motions being
included under the general term, massage. 
TO MY PUPILS.
   Do7i't drag the skin or other  tissues away from the bone.
Always make pressure  inwards.   In using two hands  upon a
part, let the pressure of the two hands oppose each other.  Feel
that you have the part between the two hands.
   I7i deep kneading don't  "wobble."  The  motion is simply a
grasp, like that  of the  bulb syringe.   Whatever facilitates  the
action of the bidb in this instrume7it will also be found advanta-
geous in  deep kneading.   The object of the two is  the same :
namely, the establishynent of a current and the emptyi7ig of the
contained part.  Study then your bulb atomizer or your David-
son's syringe.
   Don't flex the last joint  of the fingers.  In  all forms of
massage, this joint should be extended, flexion bei7ig limited to
the second joi7tt  a7id the knuckle,  or the metacarpo-phalangeal
joint.  By observing this rule you will get a broad surface for
contact with the part, a7id will give a pleasanter as well as more
effective massage.
   Always vary k7ieading  with the stroking motion, the succes-
sion being massage, one,  two, three; effleurage;  massage,  etc.
In this count, one, two a7id three represent respectively the grasp
of the two hands where both are used at the same time upon  the
part.
   I71 kneading with two hands don't make your grasp with all
of your fingers simultaneously, but  let the  fingers follow  one
another; and those of the left hand follow those of the right, the
order being:  compression of the pari by approximating the palms
of the two hands; then, the grasping of the part betwee7i the palm
and the last finger of the right ha7id, the next a7id the next, the
last finger of the  left hand, the next and the next.
   In this progressiveness of grasp, however, don't  allow any in-
terval of non-contact.   The part should always be firmly encir-
cled and the patient feel that you have her well in hand.   The
progression referred to is therefore  but an accentuation of a con-
tinuously firm pressure.
   Don't, without careful  consideration undertake to  massage
men.  Male operators are more suitable for such cases. S. E. P. 
MASSAGE.
                 INTRODUCTION.

    THE way  to  learn massage is to do it.  This
    apparently  paradoxical  statement is as true
 of  the  practice  of  massage   as  it  is of  the
 reading of foreign languages, the practice of cook-
 ery or other arts which might be named.   One may
 study the grammar of a foreign language for a long
 time without thereby becoming competant either to
 read or to speak it.   One may  pore  over  a cookery
 book without becoming able to produce a palatable
 dish.   Similarly the rules of massage, the science of
 massage, are small  matters by the  side  of the art
 which can be acquired in perfection  only by practice
 extending over months or years.   In spite of this fact
 however there  are preliminary   exercises  which
 prepare  the hands  and   make  its  acquisition
 more easy.   Among these, piano practice will perhaps
 rank, with  other exercises  which give  breadth of
 grasp to the fingers and suppleness  to the joints of
the hands.   Housework, such as washing,  ironing, 
IO
sweeping and the like, should upon first thought give
strong capable hands; but as a  result of experience
this  inference has  not been  proved  true.   Hands
much occupied in domestic duties are apt to be, on
the contrary, stiff-jointed and to have little spread of
the fingers and but little strength of grip.  House-
hold duties do not develop the  smaller muscles  and
the finer movements of the fingers and hand.   The
use of the pen and the needle also produces a hand
which is inclined to be stiff.  Almost any hand may
however be trained and developed  by perseverance
and care.   A large hand is an advantage if it is  also
pliable,  but a small hand may often  be made  to do
more work by means of greater reaching power.
  An opinion is often requested in regard  to  the
physique for  the operator  in  masage.   The main
source of fatigue in giving massage is very probably
unaccustomed positions and unaccustomed muscular
strain.  Here again any physique  can be  trained
to endurance, provided first that the vital capacity be
good  and by this is meant the  working capacity of
the heart and lungs. To ensure a good operator the
difference of chest circumference during inspiration
and  expiration should  be at least 2 inches.   2 1-2
or 3 inches would suggest still greater working pow-
er.   To test this  point take the bust measurement at
the end of  a  full inspiration and again at the end
of  a  forced expiration  and  note the  difference.
This is one of the best tests of  capacity  for  physical
work.   It is also a good test for  probable  endurance
under other  strains such  as  those  of privation or
disease.
  The massage operator must not easily get  out of
breath.  A Superintendent of a  school has said to  me,
"Can you not elaborate some  system by which  the
operator may spare her strength."  I know of no such
system which can be relied upon.  I know that there 
I T
are instruments-rollers and the like-which  are sup-
posed to take the place of the hand and by means of
leverage to economise strength.  As a tonic in nerv-
ous  conditions these do nicely, but when you come
to the true surgical massage or anatomical  massage
for surgical conditions they are  at fault.  Not  one
of these instruments  accommodates itself to the surf-
ace as does the hand.  Not one of them even imitates
the essential motions of massage.   Not one  of them
can take the place of massage, although  any one  of
them may have a very well earned place of its own.
I know of no way of  giving massage without the  ex-
penditure of the  operator's own muscular force.    An
hour's massage is for the  operator  as much exertion
as an hour's hard work in  the  gymnasium and  the
general weariness which  is produced is very much
the same.
  We come to the question of dress.   The massage
operator  should  not be restricted at the  waist,  if she
would be placed at the best advantage  for her work.
The corset and skirt  bands which  bind at the waist,
should be avoided.
  It may be superfluous to add that the utmost personal
cleanliness is required  ot the operator in  massage.
The daily bath and frequent  changes  of linen  are
imperative.
  Having prepared ourselves for the practice of mas-
sage,  we shall in our next lesson  proceed directly to
the motions of which it consists. 
12
          THE MOTIONS OF MASSAGE.  § I.

   r. In the literature of massage we find the required
manipulations referred to under the terms, Massage,
superficial and deep ; Effleurage; and Tapottement.
   2. Superficial  massage is  a term  applied  to  the
kneading of the subcutaneous tissues and skin.
   3. Superficial massage may be performed in two
ways.  The  first is by rolling  the skin  and subcutane-
ous tissues between the thumb and index finger.
   4. The first motion of superficial massage is partic-
ularly  useful in work upon the abdominal walls.   In
subjects where  this part  is very lax, the motion may
be modified by taking the opposing surfaces between
the palms of the  hands and gently  kneading the one
against the other.  The maneuvre should be repeated
only two or three times in one place.   Then  the
hands  or fingers  should be slightly  moved so as to
take in new territorry; subsequently, perhaps, return-
ing once, twice or many times to the original part.
   5. The second motion of  superficial massage is a
circular motion with the thumb or fingers by  which
the skin and subcutaneous tissues are  compressed up-
on the underlying part.
   6. The second motion of superficial  massage is
applied to the smaller subcutaneous muscles,   to  the
fibrous tissues, which closely surround  the bones,
and to the nerves at their formina of exit.   It is par-
ticularly  useful  in  work  about joints, in  work about
the eye-balls, and in work upon the muscles and other
tissues of the scalp.
  The  educated finger  will  in this motion carefully
follow  the topography of the part.   In no motion of
massage  is a knowledge of bone anatomy of  greater
use.    The trained  operator disregards the external
contour and sees  the unclothed skeleton  before her.
She penetrates the depressions of the fossae and seeks 
13
 out the foramina as she  follows the surfaces of the
 bones.
   7. A rule to be observed in superficial massage is
 not to move the finger upon the skin.   In neither of
 these motions is the thumb or finger moved upon the
 skin, but the skin and underlying tissues are  moved
 with the finger upon the opposing part.
   8. Deep  massage comprises  work upon the larger
 skeletal muscles; also upon the abdominal and pelvic
 organs  and other deep-lying parts.   It also is per-
 formed in two ways according to the organ which is
 to be reached.
   9. The first motion of deep massage  is  that used
 in work upon the larger skeletal muscles.   Massage
 of  the  skeletal muscles has been the crucial test of
 ability  in the operator.  According as he or she could
 or could not accomplish this   motion satisfactorily,
 they were or were not  good  manipulators.  For no
 motion is the ordinary  woman  less well  prepared,
 none does she find more difficult of acquisition and in
 none are bad habits more common.  Let us then first
 impress upon  our minds exactly the  object,  which
 should  be kept in view.
   10. In  massage of the larger skeletal muscles, the
 object to be accomplished,is first, to grasp a  muscle
 or  group of muscles;  and second,  to empty  this
 muscle or  group of muscles, so far as we  can, of
 blood  and  to encourage a fresh supply.   This is ob-
 tained  by squeezing the muscle and then letting it
go,  exactly as the bulb  of  the  atomizer or of the
 Davidson's  syringe is alternately compressed  and re-
 laxed.   Bear in mind then the attitude of your hand
in  the  use  of  a  bulb-syringe.  Do you not use the
palmar eminence of the thumb in opposition to the
three last fingers ?   I think that you do if you have
learned to  use this instrument  with  a broad com-
prehensive grasp. 
14
  u.   In massage of the larger skeletal muscles,
grasp the muscle or group of muscles between the
three  last fingers and the palmar eminence of the
thumb, carrying the hand at a right angle to the ulnar
border of the forearm and the thumb at a right angle
to the hand.  To grasp a muscle or group of muscles
you must be able to surround it, the grasp being at
a right angle to the muscle's length.
  12.   In applying the hand thus outstretched to the
limb,  the ulnar border of  the operator's forearm
should be parallel with the limb and the ulnar border
of the hand at a right angle to it.  The  extremities
of the thumb and index finger should be  kept out of
the way; they have no part in thb motion.
  13.   Having adjusted the hand to the part this first
motion  of deep massage  consists in alternately in-
tensifying and relaxing the grasp upon the muscles,
repeating the manoeuvre two or three times, and then
slightly shifting the position so as to take in a differ-
ent part.
  14.   An essential rule to be observed in deep mas-
sage,  also, is not to move the hand upon the skin.
Neither pinching nor friction are required. The first
motion  of deep  massage  is simply a squeezing or
grasping manoeuvre, the hand embracing, so far as
possible all of the tissues outside  of the bone.
  15.   The second motion of deep massage is used
particularly in work upon  the abdominal organs.  It
consists in compression of the parts against the under-
lying surfaces by means of a downward pressure not
unlike that used in the kneading of bread.
  16.  In massage of the abdominal organs it will be
found most convenient to  use the outspread fingers
of the nearer hand and the palm of the further hand
alternately.
  17.   In massage of the  abdominal organs the mo-
tions  should be slow and care should  be taken tc* 
 
Fi«. 6.  Krtleurage.  Used upon small parts.
                 «'il.i—2:i. 
15
avoid abruptness in the alternations.   The  pressure
should gradually increase and then gradually diminish
in intensity before the hand is moved to another part.
In this motion the operator may stand with the knees
braced against the side of the bed so as to balance the
weight  of the  body upon the outstretched hands^
Gravity thus assists in the performance of the  work
and an equable pressure is obtained.
  18 The object of  this motion  is to accelerate the
circulation of the blood in the abdominal organs and
to excite peristalsis in the intestinal  muscular layer.
These muscles belong to the group of the involuntary
muscles.  They appreciate stimulation and respond
to it very slowly. Hence, to give the best results the
impression must be prolonged, the  hands  must not
be rapidly moved from one part to another.
  19.  Effleurage  is a stroking motion which consists
in passes  of  the  hands from the extremities towards
the heart.
  20.  This motion is applied particularly to work up-
on the limbs and the neck,  the regions over the great
vessels receiving special care.
  21.  In  effleurage  upon the thighs and  upon the
neck both hands may be applied simultaneously  or
alternately ; but upon other parts only one hand can
be used, the other being required to steady the part.
  22.   Effleurage  should  be applied with  a firm,
deep  pressure,  the  hand  being well oiled.  Where
oil or vaseline is objected to  by  the  patient, talcum
powder will be found to answer the  purpose.  Unless
some lubricant is used,  sufficient force cannot be ap-
plied without giving pain.
  23.  The object of effleurage is to empty the vessels
which return the circulatory fluids to the  heart.  By
its means we may  reduce  engorgement and hasten
the absorption of matters effused from the blood. The
heart,  as a force pump, sends blood  into the arteries. 
i6
 These terminate  in a network of capillaries  which
 tunnel every part of the body.  The capillaries finally
 coalesce, forming other large vessels—the veins which
 receive the capillary blood.   The force of the heart
 has been  largely spent by the time that the blood
 arrives in  these veins and, consequently, the current
 in them is slow.
   The slowness of the venous current is a misfortune
 where a pathological congestion  has occurred. In
 congestion the smaller arteries of the part are dilated
 and the capillaries receive more than their usual sup-
 ply of blood.  The venous flow continues its sluggish
 course and, as a result, engorgement of the capillaries
 with, finally, choking of the capillaries and stagnation
 of the current occurs.
   Each throb of the heart brings more  blood to this
 -already over-supplied part and, from the pressure or
 other unnatural conditions present, the capillaries per-
 mit the escape of their  contents through the  walls.
 Inflammation and abscess may be the result.
   The stroking movement of  massage is  capable of
 averting this history.  Applied during  the period of
 congestion, not on the congested part,  but above the
 congested part, it mechanically empties the veins to-
 ward  the  heart.   On account of the  valves  in the
veins,  no  backward  flow can take place  and the
 empty lumen draws  upon the contents  behind it.  If
it  be again  and again  emptied the  capillary current
 will  be re-established, and, when relieved from ten-
sion, the arteries may recover their usual calibre, or,
in other words, recover their tone.
   It might  here be repeated that where  we use  mas-
sage for congestion, we do not work  upon the con-
gested part, but upon the part, internal to it or toward
the heart.
   Where effusion has already  occurred, the stroking
motion is further capable of hastening the absorption 
17
 of the effused matters.   It does  this by  accelerating-
 the current in the lymphatic system or  the  drainage
 system of the body.  Surrounding the elements of the
 tissues are spaces which contain the so-called juices
 of the tissues.   It is into these spaces that the nutri-
 tive portions of the blood pass  and it  is from these
 spaces or eating troughs that each little element takes
 up its portion  of food.   It is in these spaces too that
 the water  of oedema and other pathological products
 are found.  Lymphatic capillaries proceed from these
 spaces, which lymphatic capillaries coalesce and form
 larger lymphatic vessels, terminating  in the  great
 veins.
   The flow in the lymphatics is still slower than that
 in the veins, because it is not in any direct way aided
 by the heart.   The lymphatics also have  valves and
 as in the case of the  veins,  we can,   by the stroking
 movement of massage,  mechanically  displace their
 contents toward the heart and thus hasten the process
 by which effused matters are absorbed.
   The tissues may be  clogged with excrementitious
 material, not only  in local  inflammatory processes,
 but also in conditions of malaise, where, with a slug-
 gish circulation, the general health is impaired ; and
 in obstructive diseases of the liver, kidneys and other
 organs.  In these cases  also effleurage  will be of
 service.
  The irritation of muscle nerves causes dilatation of
 ihe smaller arteries and an increased supply of blood.
 Within physiological  limits  an increased  blood sup-
 ply improves nutrition and,  if we add to deep knead-
 ing an occasional stroking motion for the better emp-
 tying of the lymphatics and  veins,  we have in mas-
sage an ideal substitute for muscular exercise without
the expenditure of nervous force.
      By tapottement is  meant the clapping, pound-
ing and vibratory motions,  whether applied  by in* 
i8
 struments or the hand.
    24. Manual percussion may  be done with the fin-
 ger-tips, with  the  hollowed palmar surface or  with
 the ulnar border of the hand.
    25. Tapottement with the hollowed hand is partic-
 ularly useful where a large surface is  to be rapidly
 covered.
    26. An advantage of tapottement with the hollowed
 hand is the cushion of air retained between  the palm-
 ar surface  of the  hand and the part to be percussed.
 This cushion  of air makes contact but momentary,
 as its expansion gives an impulse to the hand away
 from the part.  Tapottement with the hollowed hand
 is not only remarkably effective,  but it is also as a
 rule very agreeable to the patient.
   27.  Percussion with the  finger  tips or the  ulnar
 edge of the  extended hand is used where the work is
 upon a narrowly restricted part.
   28. In percussion from the finger tips, the fingers
 should be semi-flexed and the movement  should  be
 made from the wrist, or the fingers  may be extended,
 the wrist-joint stiffened and the motion be made with
 the vertical hand from  the shoulder or elbow.

            GENERAL MASSAGE.  § II.

   29. By general massage is meant a systematic  ap-
 plication of  massage   to  the general body  surface,
 excepting \isually the head, neck and breasts.
  30. In applying general massage the patient should
 be  disrobed,   excepting  perhaps  the  undervest,
 wrapped in a blanket, and lying upon  a measurably
 firm surface.   A lounge is seldom resistant enough ;
 a  well-mattressed  bed is to be preferred.  A double
 blanket will  be found more manageable than a single
 blanket also for enveloping the patient.    The opera-
toi  should stand with  this blanket  extended before 
19
 her ready to  enwrap  the patient immediately upon
 emergence from her clothing.  A second single blan-
 ket or soft shawl will be needed in the course of the
 application and should be at hand.
   31.  The operator prepares herself  by the precau-
 tions mentioned in the introduction to these lectures.
 She is clothed so as not to restrict motion,  she has
 had her daily bath and is freshly apparelled,so that no
 hint of decomposing  perspiration lingers about her.
 It should be borne in mind that the muscular exercise
 of the operator in massage resembles that of the la-
 boring man and that without special  attention to the
 minutiae of cleanliness she will be apt to carry about
 with her the same odors.
   32.  In addition to these  preparations and before
 touching  the  patient,  the operator should wash her
 hands.  Why must she do  this when she has left
 her home with  her hands  perfectly   clean ?   In  the
 first place, because we can scarcely exist for half an
 hour without gathering dust upon the exposed parts
 of out bodies.  In the  second place,  because  the
 moral effect upon the patient is good.   There is con-
 siderable repugnance on the part of many women to
 being touched by strange hands.  One reason of this
 repugnance is that they cannot be sure that these hands
 are perfectly clean.  Do not let this doubt haunt  the
 mind of your patient.   The comfort of assured cleanli-
 ness is, to the sick, greater than, perhaps, the well know.
   33. The order of procedure  in general massage
 varies  with  different  operators.   After  you have
 worked for a time at  the  business  you may find it
 desirable to adopt some plan of your own.   To start
 you, however, 1 will give you a programme which
 has stood the test of some practice and has been fair-
 ly satisfactory.  In this programme your patient first
lies upon the  side, facing you  and you commence
with the finger tips of the outside arm.  Passing the 
20
arm and shoulder you next work upon the back and?
then the outside leg.  During this time the patient
has not changed her position.   You now place her
upon her back and work upon  the other leg or the
one nearest you; then turn her slightly  towards
the other side and massage the side of the trunk and
the shoulder thus exposed ; then return her to the po-
sition upon her back and work upon  the remaining
arm, proceeding  from the shoulder downwards. Last
you subject the abdominal wall and  the abdominal
contents to superficial and deep  massage.  It will be
seen that you need scarcely lift  your hand  from the
surface in the course of the application, each part be-
ing continuous with the one next in hand.
  34.   The amount of time to  be consumed in gen-
eral massage must be correctly apportioned to the
various parts or the treatment will either be prolonged
so as to fatigue the patient or will be unduly short
As a rule, one hour is given to the whole  application.
Of this hour twenty minutes  maybe  apportioned to
the work upon the back, twenty minutes  to  that up-
on the lower extremities and twenty minutes to that
upon the abdomen and arms.  The  first  arm  will
thus receive but  about  five minutes of the entire
time.
  35.  In massage  of the arm  proceed  gently but
quickly  over its surface.  Taking up the little finger
subject it to superficial massage performed according
to  5  and having completed this motion, hold its ex-
tremity firmly between the left thumb and fore finger,
passing the right thumb and  fore finger by one or
two quick motions down its inner and outer surfaces,
the motion being  from the extremity to the hand.
This motion is intended to empty the veins and lym-
phatics which  accompany the  arteries,  whose pulse
may often  be obtained in this location.   Having
finished  these  two motions  in  the  case  of  one 
 
Fiu. 1.  Kneading motion.  Used about joints and over
                 Hat bones.  '5 — 7. 
21
finger, you  quickly  take up  another and  another
and  having  finished the lingers  you  pass to the
hand.
  36. In work upon  the hand the first motion is a
superficial massage of the dorsum  according to  5,
then a deep massage  of the thenar and  hypothenar
eminences  according to  10  followed by effleurage
performed with the side of the thumb  upon the dor-
sum in the interosseus spaces, the  motion  being to-
wards the wrist.
  ^y. The forearm now claims your attention.  Here
and  in the succeeding part it will be of assistance to
bear in mind the location of the great muscle groups
and the distribution of the main vascular trunks.  In
the forearm we have the flexors of the hand upon  the
anterior surface and  the extensors of  the hand upon
the posterior surface separated posteriorly by  the
ulna.  In taking hold of the foreiirm exclude the ulna
so far as you can from your grasp,
  38. In massage of the forearm  employ the motion
described in   10, alternating with the motion of ef-
fleurage.  This is obtained  by steadying  the part
with one hand and  passing the other from the wrist
to the elbow, putting the most pressure over the rad-
ical pulse, two or three motions of deep massage  be-
ing quickly followed  by the  motions of effleurage,
the order being massage, effleurage, massage,  effleu-
rage, and so on.
  39. In the arm we find two great muscles the biceps
and  the triceps  forming respectively its inner and
outer surfaces.
  40. In massage of the arm grasp  the  biceps  with
one hand and the triceps with the  other, using  the
first  motion  of deep massage,  10,  varying it with
effleurage as before.
  41. In effleurage of the arm,  pressure is especially
made along the inner border of the  biceps where  the 
22
veins accompanying the brachial artery are found.
  42. Massage of the shoulder in general or medical
massage resolves itself into massage of the deltoid, a
large triangular muscle haviog  its origin along  the
,)uter third of the cavicle and the spine of the scapula
and its insertion upon  the outer surface of  the  arm
one-third of the distance from the shoulder joint.
  43. In work upon the deltoid muscle we may vary
the first motion,  10, with the second motion of deep
massage,  15.  Effleurage should here also be used
at frequent intervals.
  44. In effleurage of the deltoid, both hands are to
be employed the motion being toward the neck.
  45. Having finished this part,  shoulder and  arm
should be covered with the extra blanket with  which
you  have  been previously provided,   then the en-
veloping blanket should be  slipped  down from  the
back.   Massage of the back  practically embraces
that of the muscles  over the scapula, properly  be-
longing to the shoulder but,  by their position reached
in connection with underlying and adjacent parts of
the back.
  46. Work upon the scapular region is performed by
means of the second motion of deep massage,   15.
This motion is continued to the adjacent muscles
over the ribs and along the spinal column.   The neck
muscles are grasped from the back by the first motion
of deep massage,   10.  Effleurage is upon the back
replaced by friction.
  47. Friction of the back may be conveniently ap-
plied in either a transverse or a longitudinal direction.
Transverse friction of the back is obtained as follows:
Having the patient in the position already described,
upon the side and facing the operator,  the left hand
of the  operator  is extended and drawn transversely
across  the back, from the further to the nearer side,
the palm being applied to the part.  Beginning a 
23
second later the right  hand  is projected or pushed
over the same territory but in an opposite direction
from the nearer to the further side, crossing the track
of the left hand in the median line or over the spine.
Having thoroughly reddened the skin by this motion
it  may be  varied by  friction in the longitudinal
direction.
  48.  Friction  in the  longitudinal direction is ob-
tained by using  the two hands alternately.  With the
patient still  upon her side and facing you, extend the
fingers and pass the tips from  the coccyx  to the neck
along  the  hollow  of the spine.  Without lifting this
hand or  losing your hold upon  the skin, keep the
position obtained at the base of the skull and with the
fingers of the other hand similarly extended and stiff-
ened pass from  the neck downwards.   If it be kept
in mind that the object of the motion  with the left
hand is to prevent too great displacement of the skin
by the right  hand during its part of the maneuvre,
these directions  will perhaps receive better apprecia-
tion and closer compliance.  Quickly follow the right
hand with the left, the  left with the right, and so on.
While the motions themselves should not be hurried,
the intervals between them should be short.   In the
art of passing  quickly from one motion to another
the  massage operator might profitably take a lesson
from the conjuror in  legerdemain.   Observe  how
slowly,  how deliberately he is proceeding when,
presto,  he  is doing  something else in the same de-
liberate  way.     Massage  is not a  rapid  motion,
effleurage is not a rapid motion or should not be, but
the transition time between the two should  be well-
nigh infinitesimal.
  49. Both transverse and longitudinal friction of the
back are at  first  difficult because thby require simulta-
neous contrasted motions. Upon ordinary occasions
we perforin only similar motions simultaneously. 
24
  It takes  some mental  grasp as  well as  some
practice  to  give to  each  hand a separate control.
The motions can however  be  learned  by  anyone.
To  the patient they are perhaps  the  most enjoyable
of all the motions of general massage.
  50.  Friction  of the back should not be attempted
with a moist skin.  Where the patient is perspiring the
surface should be first thoroughly dried with  a  towel
or  the *alcum  powder may  be sprinkled  upon it.
Where uie  operators hands are moist  the  powder
should be used also.
  51.  We now  pass  to  the gluteal muscles.   These
should not be neglected as they  are of great import-
ance in assisting man to the upright  position.  They
arc especially used in rising from the sitting position,
mounting stairs,  climbing  and  analogous exercises.
  52.  In work upon the gluteal  muscles, we use the
second motion  of deep massage,  15.  Here the op-
erator  should   make herself  particularly  familiar
with the  bone  Anatomy of the part and should be
able to recognize the  head of the femur,  the tuberos-
ity  of the ischium and the great sacrosciatic  notch.
Deep  massage  will here reach the sciatic nerve as it
emerges  from the pelvis and some patients will benefit
by  attention  to this region. The force used should be
however  but gradually and cautiously increased.
Gentle but persistent  work is as a rule more effective
than violent  efforts in all inflammatory  conditions.
  53.  In massage of  the thigh but little attention  need
be paid to the muscle groups as these overlie each-
other to form a  more or less  compact mass.  As   a
rule it is most  convenient to grasp the  front  of the
thigh with the one  hand and the back with the other.
  54.  In work  upon  the thigh,  use  the first motion
of deep massage,   10, varied by  effleurage, here  to
be  performed witn both hands.
  55.  In  effleurage of the thigh,  special  pressure 
Fi«. 'i.  Kneading motion.  Used about joints and over
                 flat bones.  ^6—7. 
 
should be made in the  popliteal  space under the
knee and along the inner  half of the  front of the
thigh.
  56.  The  muscles of the leg are chiefly massed up-
on its posterior surface.   Excluding the tibia so far
as possible, the limb.is grasped with the two hands
either from the front  or  the back.  The motions are
as on the preceeding part.
  57.  Effleurage  of the leg can be  performed with
one haad only, the other hand  being  required to
steady the foot and the limb. In effleurage of the leg
the hand passes first over the ankle, special  pressure
being made with the fingers behind the inner mal-
leolus and upon the dorsum of the foot.  If in doubt
about these locations , feel for the pulse which  is to
be found in the parts. Bear in mind that the pulse is
valuable,  not as locating the vessel  you  desire to
influence  but only as locating  one  contiguous to it.
The larger arteries are always accompanied by  veins
and a  complicated mass of lymph channels. Effleu-
rage is intended to hasten the flow  in   these vessels
which return fluids to the heart.
  58.  Another caution to be observed  in effleurage
is not to neglect the general  surface of  the part be-
cause of special attention  to the  regions  over the
great vessels. The whole body is in one aspect but
a mass of lymph spaces  or avenues along which the
elements of the tissues are born, live and die.  Sub-
cutaneous emphysema or oedema by inflating  these
spaces demonstrate very graphically their  existance
and  their wide range of extension over the body.
Pressure  will, properly applied any  where, empty
lymph channels.  In effleurage therefore it is desira-
ble that the part  should  be  surrounded by a firm
even pressure in addition to  the special indications
described.
  59.  In massage of the foot, use tor the dorsum the 
26
second motion of superficial massage,   5,  and for
the plantar surface, the first motion of deep massage,
 10,  as in work upon the hand.
  60. In effleurage of the foot we may follow  the
interosseous spaces where these can be easily reach-
ed. In many cases however better results will be ob-
tained with the two palms , one being upon the sole
of the foot under the instep and the other  upon  the
dorsum.  Alternate motions are here made   with  the
two  hands, the direction being upwards or towards
the trunk.  These  motions are very short and consid-
erable force may be used,  They  can be  continued
by effleurage of the ankle, the leg and the thigh as
already described.
   61. The order of  procedure in work upon the sec-
ond  half of the body is foot,  leg,  thigh,  gluteal re-
gion, side  of trunk,  shoulder, arm,  forearm  and
hand.  It will be observed that we do not in this  ord-
er strictly follow the rule that work should begin up-
on the distal extremity of the limb.  In work upon
the first upper extremity and in that upon the second
lower extremity it is maintained; in work  upon the
other two, it is not.  We do however always proceed
from the distal extremity of the segment under  con-
sideration, whether it be  arm, forearm or some other
part. The essential  element of the rule  is  thus  pre-
served,  all displacement of fluids being towards the
heart.
   62. In massage of the abdomen we work first up-
on the skin, using the first motion of superficial mas-
sage,  4; then upon  the subcutaneous tissues  and
muscles, taking these up between  the  palms  of the
two  hands where there is a great deposit of fat.  Last
the contents of the abdomen are to  be  kneaded  by
the second motion of deep massage,  15.
   63. Ten minutes are usually employed upon the ab-
domen  in the course of  general  massage.   Where 
 
h'm. 5.  Kneading motion.  Used to reach the stomach
                and the colon.  *lu». 
27
 work upon the skin and muscles is disagreable to the
 patient this must be omitted and the operator pass
 directly to the motion of deep massage.
   64. To reach  the colon with massage,  place the
 fingers under the small of the back  and  with the
 thumbs extended upon the anterior abdominal wall
 include the trunk so far  as  possible in your grasp
 and apply to it the first motion of deep  massage,
 kneading it as though it were a great thigh or arm.
 In no other way can we include the colon and thor-
 oughly subject it to  pressure.  The second  motion
 of deep massage applied to the  abdomen,  affects
 chiefly the small intestine and stomach. Much tact
 is required in work upon this part as it is  apt to be
 at least at first, very disagreable to the patient. Del-
 icacy in the performance of its maneuvres will how-
 ever  overcome the patient's  objections  so that she
 may  even learn to like  the motions.  I have  known
 one patient who would sleep during their performance
   65. An exception to the rule for centripetal massage
 is found in practice upon pugilists after exercise. We
 are told that rubbing is in these cases centrifugal or
 toward the extremities. The reason is not difficult to
 find.  The object  of the  treatment is here not accele-
 ration of the circulation which is already in an excit-
 ed state of activity. It is rather intended to quiet the
 action of the circulatory forces and relieve the vascu-
 lar tension,  particularly in the brain. Centrifugal  ef-
 fleurage accomplishes this by detaining fluids from
 the heart. It is idle to  fight with facts and when a
 man like the great Sullivan insists upon being rubbed
 down and not up it is  safe to say that a good  reas-
 on underlies the  practice. It is  wiser to hunt for the
 reason than to insist that the treatment has been in-
 efficiently applied. Horses too are  "rubbed down"
 not up after exercise.   Rules for this practice may be
formulated as follows, 
2o
 .^66. In conditions ot excited  heart's action  effleu-
rage may  be beneficially applied  centrifugally or
away from the heart.
  67. The  object of centrifugal effleurage is the tran-
quilizing of the circulation by slowing  the venous
current and detaining fluids from the heart.
  68. Centrifugal effleurage  may be therapeutically
useful   in  conditions of  sleeplessness with flushed
face and overexcited brain.
  69. Cold feet  and general  discomfort  sometimes
follow  massage.   Dr.   Weir  Mitchell    has   re-
marked that all patients do  not  bear general mas-
sage well.  This result is often due to awkwardness
in the manner of its application. The smaller arteries
are surrounded by circular muscle fibres which control
their lumen or calibre.  These •muscles are under the
control of nerve ganglia or cells which communicate
on the one  hand with the muscle and on the other
hand with  the skin.  These  nerve  cells  stand all
like little  sentries,  ready to  take alarm and  give
warning. It is not enough that our patient should be
morally willing to undergo the treatment. These in-
voluntary muscles and independent sentries must al-
so  be  taken  into consideration. Our work must be
approved not only by the higher intelligence of the
brain but also by these thoroughly stupid little atoms
of sensibility.  We must please them if  our  patient
is to be benefitted. If disagreable to them, they  are
capable of  defeating us by shutting up the arteries to
their smallest possible calibre.   The  longer we work
upon the limb, the colder it becomes because by the
emptying of  the  veins we  are reducing  it to a well-
nigh bloodless condition.
  70. Where general  massage leaves the hands  and
feet cold it has often  been carelessly or injudiciously
applied. If after having reduced the  violence of  con-
tact by the  use of powder or oil,  the difficulty is  not 
:q
overcome,  the operator  should be  changed or the
manipulation  discontinued.
  71. General massage, properly applied, lowers the
pulse, warms the extremities and leaves the  face
pale, In cases where massage produces coldness of
the feet the face will be found flushed and the pulse,
accellerated.
  72.  Very fat  people often fail  to bear  massage
well,  several days lassitude not infrequently follow-
ing  its use.
  73.  In the  case of  a fat person both massage  and
effleurage should be gentle  and  neither should be
continued for more than  a half hour  until tolerance
has been assured.
   74.  In the  Weir Mitchell*   or  Playfairf treatment,
general massage is given daily one hour at a time or
twice daily, one-half hour at a time.  Dowse| recom-
mends the latter method, the morning application to
cover the  lower extremities and abdomen  and the
 evening application, the upper extremities, head and
back. As the invalid gains  strength  massage is re-
 placed by passive,  active and resistive  movements. ||

               LOCAL MASSAGE   § III.

   75. Massage of the Head  is employed in cases of
 sleeplessness, in  cases of  neuralgia of the cranial
 nerves and in rheumatism and gout of the scalp.
   76. In work upon the scalp we  use chiefly  the sec-
 ond motion  of superficial massage, *fio. Steadying
 the head with the thumbs and last fingers the manip-
 * S. Weir Mitchell:—Fat and Blood,  J. B. Lippiucott & Co., Philadel-
phia, 1884.
 t Plavtair;—London Lancet, May 28, 1881.
 t T S  Dowse:—The International Medical Annual, 1889, p, 72.
 il S-'hreiber—A Manual  of Treatment  l>y  Massage  and Methodical
Muscle Exercise , Lea Bros. & Co., 1887. (This hook gives very full direc-
tions and diagrams illustrating the performance of these motions.; 
3°
ulation may be performed with the tips of the forefin-
gers ; or the thumbs may be employed in the manip-
ulation, the fingers steadying the head.
  77.  In massage of the scalp great care  should be
taken to move the skin with the fingers, the motions
being very short and pressure toward the bone.
  78.  Massage of  the scalp may be performed with
the patient in the recumbent, the  semi-recumbent or
the upright position.  If recumbent the patient should
lie with the face turned away from the operator.   It
upright the patient may sit upon a chair, the operator
standing or sitting upon a somewhat  higher chair or
stool behind her.  A third and more comfortable posi-
tion is obtained with the operator sitting  on the bed
with one knee supporting the pillows and the patient
in a semi-reclining position.  Gravity here assists the
manipulation and  yet the  patient is  not wearied as
when upright.
  79.  Tenderness  with oedema  or puffiness  of the
scalp will  be found in some cases.   With the  reduc-
tion of these local swellings relief from  discomfort
and sleeplessness will often follow.
  80.  From twenty minutes to a half hour may be
advantageously occupied with massage of the scalp.
The manipulation should be repeated daily.
  81.  Massage of the scalp should be combined with
effleurage of the frontal and temporal regions and
with massage and  effleurage of the neck.
  82.  Effleurage of the forehead and  face is determ-
ined by the course of the veins  being outward and
downward, the fingers following  the temporal veins
directly in  front of the ear and continuing the pres-
sure over the neck and the external jugular vein.
  83.  Massage of the Neck may be performed either
with the operator in front of the patient or in the rear. 
3*
When combined with massage of the scalp the latter
is the more advantageous position.
  84. In massaging the neck from behind, the oper-
ator may  stand, the patient occupying the sitting-
                       Fig. 9.
             Massage of the Neck—Hoeffinger.

posilion ;  or the operator may sit, the patient occupy-
ing the semi-reclining  position already  described.
The operator supports the patient's head upon her
chest and uses both hands in the manipulation.
  85.  The muscles of the neck may be giasped from 
32
 the back with the second motion  of deep massage.
 The parts about the base of the skull should be man-
 ipulated with the finger tips, using the second motion
 of superficial massage, firm and deep pressure being
 made.  Lastly these motions should be intermittently
 combined with effleurage of the whole neck.
   86. In effleurage of the neck the  operator's hands
 should  encircle the neck excluding  the trachea and
 larynx.   In this manner the operator's thumbs meet
 at the spine while the finger tips approximate closely
 to  the trachea upon each side.   The pressure should
 be firm,  the motion being  downwards from  the
 maxilla to the chest.
   87. The object of effleurage of the  neck is to hasten
 the current, particularly in the  external  and  internal
jugular veins.   The  external jugular extends from
 the angle of the jaw to the  line of junction of  the
 inner with the external two-thirds of the clavicle.   It
 crosses the sterno-mastoid muscle and can often  be
 distinctly seen.
   88. Effleurage upon  the  antero-lateral aspects  of
the neck with the palmar surface of the hand will
empty the external jugular vein. The internal jugular
lies internal and more deeply, being located near the
trachea upon each side.
   89. To empty the internal jugulars the finger tips
must press deeply and firmly into the space between
the sterno-mastoid muscle and  the trachea.
  90. The external jugular vein conveys blood espec-
ially from the scalp, consequently effleurage  applied
to this  vessel  assists  circulation  in  the temporal
regions  and scalp.
  91.  The internal jugular vein receives blood from
the face, the mucous  membranes  of  the  mouth
throat, nose and ear, also a large part of the return
blood from the brain.  Effleurage of the internal jug- 
33
ular assists circulation  particularly  in  the  mucous
membranes of the head and in the brain.  It is indeed,
as suggested by Jacoby,* the only form of massage
               Fig. 4-
Massage of the Neck.—Gerst.—First Position.
* Massage in Nervous Diseases, by George W. Jacoby, M. D. 
34
by which we have any direct cerebral influence.   It
follows that  the  most important  element  of neck
massage  is  the stroking motion  over the internal
jugular veins.
Massage of thk Neck.- Cerst.—Second Position. 
35
  92. A second method of applying effleurage to the
neck is that recommended by Gerst, who first ex-
tended the field of massage to the neck and demon-
         Fig 6.
Massage of the Neck.—Gerst.
      Third Position, 
36
strated its  value  as a method of  treatment.   The
operator here stands in front of the patient, who ex-
tends the head, making the trachea prominent.   The
operator then places the two hands palms upward so
that the ulnar borders are just beneath  the rami of
the lower jaw, the little fingers being closely applied
to the mastoid processes  or prominences behind the
ears.  The ulnar  borders  are then carried directly
downward and outward, the palms of the  hands
being brought into contact  with the lateral aspects of
the neck.  The radial surfaces are next brought down-
ward, the  tips of the thumbs passing between the
mastoid muscles and the trachea compressing the in-
ternal jugular veins.  The successive steps of this
motion are well shown in the accompanying diagrams
constructed under the direction of Dr. Jacoby, and by
his kind permission reproduced from his  plates.
  93.  A  third  method of neck massage is that de-
scribed  by Weiss  as being useful  in  children and
persons having long delicate necks.  We quote from
Dr. Jacoby's work the  description of this motion.
"The operator places himself opposite  his patient,
joins  the fingers  of his  hands behind the cervical
spine, and then with the thumbs performs stroking
movements downwards, the movements  being slow
and gentle, and  afterward . more  energetic.   The
thumbs  are thus  moved from the inferior maxillary
downward to the  clavicle, stroking partly the  region
of  the internal jugular vein  and  partly the  lateral
regions  of the neck.   The clavicles  having been
reached, the thumbs are lilted and carried back to the
starting point without touching the neck."
  94.  A  fourth method of  neck massage is Gerst's
modification, where the patient must apply the man-
ipulation himself.   In this case the patient bends the
head backward, places the palm of his  hand with 
                         37

the fingers flexed against the neck so that  the thumb
is upon one side and the four fingers upon the other.
The anterior part of the neck is  then compressed
somewhat forcibly, and the hand  is passed wilh a
                Fig. 7.
        Massage of the Neck.—Weiss.
For Children and Persons with Long, Delicate Necka. 
38
stroking motion downward, the other hand succed-
ing the first, rapidly, in the manipulation.
  95. In neck  massage a disadvantage will be  en-
countered in the fact that close pressure over the re-
gion of the internal jugular will irritate the laryngeal
nerves and cause cough in some  cases.  To obviate
this  difficulty pass the thumbs or fingers alternately
down one side  and then the other.   The larynx will
be thus simply displaced without compression.
  96. In the course of neck massage faintness may
also occur  in  rare  cases.  This will be due to the
cerebral anemia  produced  by  the  manipulation.
When  faintness is  apparent the patient should be
placed  in the recumbent position and the manipula-
tion suspended.
  97. Neck  massage may be used  in the treatment
of headache from  cerebral congestion, in a number
of other brain affections, in tonsillitis, in catarrhs of
the throat, nose, larynx and ear, in cutaneous wounds
of the  scalp, and fractures of the skull; also, in ery-
sipelatous inflammations of the face and acne.
  98. Applications  of  neck massage may be made
three times daily, of ten minutes each.
  99. Self-application, while inferior to the two hands
of a skilled manipulator, may be  quite effective.   Dr.
Gerst mentions using it in his own  person whenever
threatened with  a nasal or larygeal  catarrh.  Tooth-
ache may be, at least temporarily, relieved; while
headache and other phenomena of  cerebral conges-
tion may be ameliorated by its means.
  100.  Massage  of the Breast  is employed in cases
of obstruction of the milk ducts  or "caked breast."
  101.  In massage of the breast we combine knead-
ing with effleurage.   In kneading  the breast,  both
the first and second motions of deep massage  may
be employed, the cake or tumor being the part espec-
ially subjected to treatment.   Kneading  should  be 
39
alternated with the stroking motion,  as in  other
parts.
  102. In  effleurage the breast  is  grasped with the
thumb and forefinger about an inch from the  nipple,
the motion being toward the nipple in all cases.   It
will be obvious that this motion is precisely that em-
ployed in milking cows.  Plenty  of vaseline should
be used.
  103. From  fifteen  minutes to  two  hours may be
advantageously employed  in breast massage.   If
effectively performed,  the breast is  relieved of the
accumulated milk and the application does not have
to be  repeated.  One should not be  discouraged  in
this manoeuvre because  the patient insists that the
breast contains no milk.  Wherever there is harden-
ing of the tissues  milk can usually be obtained and
complete relief will follow.
  104. As a  contraindication to the use  of  breast
massage may be mentioned inability to express milk.
"Rubbing" without the expression of milk invariably
does harm.  As a second contraindication, suppura-
tion should be mentioned.  Massage is a prophylac-
tic effort, useful, as a rule, only during the first three
days of breast symptoms.   The initial chill and fever
do not, however, contraindicate its  use.   Even after
a considerable elevation of temperature prompt reso-
lution  may follow an hour's massage.
  105.  It is apparent that while a skilled manipulator
may almost eliminate abscess of the breast from the
list of puerperal discomforts, a poor manipulator can,
on the other  hand, precipitate this  accident and do
incalculable harm.  This fact explains  the  almost
universal opposition of physicians to the treatment.
As  a  third and most important  contraindication  of
breast  massage is, therefore, the  absence of a direct
order for its application from your physician.
  106.  To become skilled in breast massage,  special 
40
practice in an  obstetric  ward is required.  Hospital
practice is essential, because there the results of your
inexperience can be speedily corrected.   You should
many times have succeeded in cases under the eye of
a skilled physician  before essaying  massage in  the
case of  a private patient, or one separated by 12 or
24 hours from her  doctor'3 visit.   So  pronounced,
however, is the relief given by the successful treat-
ment that it would appear as though every hospital
nurse should have  this  practice as a part of  her  ob-
stetric training.
  107. Massage of the Abdomen. This application of
massage is advised  for dilatation of the  stomach and
for habitual constipation.
  108. The  motions  of abdominal  massage  were
given in connection with general massage (^[ 62-64).
With the patient upon the back take up and knead
the skin between the thumb and index finger by  the
first motion of superficial massage (^[ 3).  Next take
up the subcutaneous tissues also using  the palms of
the two hands where there is  a great deposit of  fat.
Knead the contents  of the abdomen  by the  second
motion  of  deep  massage  (*[ 15-18).   This  motion
consists in compression of the parts  against the  un-
derlying surfaces by means of a downward pressure
not unlike that used  in the kneading of bread.  In
massage of the abdominal  organs it  will be found
most convenient to use the  outspread fingers of  the
nearer hand and the palm of the further hand altern-
ately.   In massage of the abdominal organs the mo-
tions should be slow and  care should  be taken to
avoid abruptness in the alternations.   The pressure
should gradually increase and then gradually dimin-
ish in intensity before the hand is moved to another
part.  In this  motion the operator may stand with
the knees braced against the side of the bed so  as to
balance the weight of the body upon the outstretched 
41
hands.   Gravity thus assists  in  the performance of
the work and an equable pressure is obtained.  The
object of this motion is to accelerate the circulation
of the blood in the abdominal organs and  to excite
peristalsis  in the intestinal muscular  layer.  These
muscles belong to the group of the involuntary mus-
cles.   They appreciate stimulation and respond to it
very slowly.  Hence, to give the best  results the im-
pression must be prolonged, the  hands must  not be
rapidly moved from one part  to  another.  To reach
the colon with massage, place the fingers under the
small of the back and with the thumbs extended upon
the anterior abdominal wall include the trunk so far
as possible in your grasp and  apply to it the first mo-
tion of  deep  massage, kneading it as though it were
a great thigh or arm.   Where  the patient can lie upon
the face a  very effective addition to  the  described
motions will be  found in work upon the sacral  and
lumbar regions.   Here the ascending and descending
colon may be readily reached,  one hand being applied
upon  each side  of the spine.  Finally, finish  with
tapottement,   applied  over the  sacral and lumbar
regions  with  the  doubled fists,  the extended ulnar
border or the  hollowed hand. The bladder  should
be emptied in all cases before applying abdominal
massage.
  109. Abdominal  massage may be used  for from
fifteen to thirty minutes one, two or three times a
day.  Berne* applies  massage for  twenty minutes
once a day for constipation and in 18 to 30  days  ob-
tains  a  cure. Eccles, f  on the contrary, uses mas-
sage for dyspepsia two or three times a day.  Berne's
method corresponds very nearly with that given here ;
while that of Eccles  adds percussion of the abdom-
inal wall as an important element in the treatment.

    * Berne—Jour, dc Med. de Paris, Jan. 2, 1887.
    t Eccles—Br. Med. Journal, Sep. 3, 1887. 
42
  no. Contradictions to the use of abdominal mas-
sage  are  found  in  the presence of  inflammations,
such as peritonitis, tumors, pregnancy and calculi of
the urinary and gall bladders, although even in these
cases epigastric massage may be sometimes advan-
tageously employed.
  in. Unpleasant symptoms are  not inrrequently
associated with abdominal massage.   The first ap-
plications are apt to be  disagreeable to the patient on
account of the  peculiar sensitiveness  of the skin of
the part.   The  undervest should be retained between
the hand and the skin at least for a time in such cases.
Berne tells us that in many of his cases the first ap-
plications  were followed  by pain which  persisted
for  a number  of  hours.   The nurse is  advised to
avoid  manipulations  which  produce  pain, to  use
greater gentleness and  to be satisfied with the more
gradual accomplishment of her result.  Eccles tells
us further that he has found a considerable degree of
depression following abdominal  massage, the pulse
being lowered from 20 to 30 beats in some cases and
the hands and feet being left cold.  This result is not
referred to by  any other writer in connection  with
abdominal massage and it occurs to us that the cause
is to be sought  in the peculiarities of Eccles' method,
among  which  percussion  is  the  most  prominent.
Percussion  powerfully  affects the nervous  system.
Of all the motions of massage, JacobyJ ranks it first
in importance in the treatment of nervous disorders.
The  abdominal reflexes powerfully affect the heart.
A blow upon the epigastrium is, as we all know, fre-
quently fatal by directly inhibiting or depressing the
heart.  Abdominal skin reflexes can diminish  the
pulse.   This was distinctly  proved   in  a  series of
experiments  conducted by  the  author || with  the
tjacobv—1. c.
II Post—N. Y. Medical Record, Sep. 30, 1883. 
43
 faradic brush.  This instrument applied to the skin o\
 the  back or the abdomen  increased blood  pressure
 and lowered the pulse in some cases ten beats.  In
 these cases it was supposed that local reflex contrac-
 tion of  the  blood  vessels of the abdomen occurred
 with increased arterial pressure, which  in turn pro-
 duced according to the laws of the body slowing of
 the heart.   That there was  no general contraction of
 arteries is proved  by the fact that the  hands and
 feet remained warm and the general feeling was one
 of "bien-etre." In Eccles'  cases  we can only sup-
 pose a more profound impression causing general
 vaso-motor stimulation with phenomena  resembling
 those of chill.   The advantages  of  such  an uncom-
 fortable result are difficult to understand.  We would
 therefore not adopt his abdominal percussion except
 cautiously and in cases  where confidence had  been
 already assured.
   112.  Massage of the  Pelvis is now  applied by a
 number of reputable physicians, among  whom are
 Dr.  Reeves  Jackson,* of Chicago, and  Dr. H.  T.
 Boldt,f of  this city.  It is used for relief of  displace-
 ments of the uterus, rectocele, cystocele,  prolapse of
 tne rectum,  floating  kidney, incontinence of urine,
 due to relaxation of the sphincter, and in  the various
 chronic and sub-acute parametric inflammations.
  113.  Massage of  the pelvis is  performed  with the
 right hand upon the  hypogastnum, the index finger
 of the left  hand being in the vagina to exe-t counter-
 pressure and to steady the part.   In some cases the
 thumb of the left hand is placed  in  the vagina and
 the index ringer in the rectum,  where a large exuda-
tion is to be removed.
  114.   Applications of pelvic  massage may vary

  •Jackson—Tr. Am. Gyn. Ass'n, Vol. V.
  tBoldt—Am. J. Obst., Vol. XXII.. No. 6, 1S89. 
44
in length  from three minutes to three-quarters of an
hour.  It  is not probable, however, that nurses will
for the present at least be required to undertake this
treatment.
   115.  Massage of the Coccyx is used for periosteal
and articular pain.
   116.  Massage of the coccyx is performed with the
index finger of the  right hand in the rectum  and the
left hand over the sacral or coccygeal regions in the
back.  The hands  should be  thoroughly  cleansed
before undertaking  this manoeuvre.
   117.  In massage of the coccyx the two hands are
simultaneously employed,  the  second  motion  of
superficial massage being used.  In this  manipula-
tion the internal surface may be found ©edematous,
and the articulation between the sacrum and coccyx
tender.  Enlarged lymphatic Aressels and  lymphatic
glands may  also be found upon the internal surface
of the bones.    Proceed  gently  in these  cases, and
with the dissipation of the lymphatic engorgement
pain and tenderness will be relieved.
   118.  Massage of the  coccyx may be  continued
from fifteen to  thirty minutes and repeated  daily or
twice daily, as required.
   119.  Massage of the Limbs* is used for the exuda-
tions of bruises, contused wounds, sprains and frac-
tures.  It  prevents the organization  of  lymph, the
formation of  adhesions, and, in fractures, also,  limits
the amount of callous  and the subsequent distortion.
   120.  Massage is applied for surgical injuries three
or four times a day, fifteen minutes each time.
   121.  Effleurage is the essential element of surgical
massage.   In the case of a bruise, with extravasation,
but  with  unbroken  skin, the  whole  surface of the
part is subjected to the treatment.   In the  case  of

   ♦Gerst—Ueber den. Ther Worth tie'" Massaj.-r, Wur/buig 1879. 
4S
wounds and fractures, however, effleurage is applied
above the bandage only, especial care being taken to
empty the principal veins.  In all the forms of local
effleurage vaseline should be liberally used.
   122.  Massage of the Hand and Arm has been used
in "writers'cramp."
   123.  In  massage for  this purpose, treatment is
applied twice daily and continued  for from two to
four weeks.  Passive, resistive and active movements
are combined with the massage in this treatment.
   124.  Massage of the Eye *  is used by some oph-
thalmologists in affections of the conjunctiva, cornea,
sclera and ciliary bodv.
   125.  In  ordinary applications to the eye, the lids
should  be gently closed and drawn a little tense by
the fingers of the operator  and then lightly stroked
by quick  passes of the thumb, index finger or a cot-
ton pledget.   Corneal and circumcorneal lesions may
be rubbed by a circular motion.  In the case  of the
lids, the movement should be  from the internal to
the external canthus along the upper or lower margin
of the  cartilage, and  continued out and  down the
cheek along the course of the vessels.   It  should be
employed at intervals of one to three days.
   126.  Massage of the eye is contraindicated  where
persistent redness of the conjunctiva follows its use.
All injection  caused by the treatment should  disap-
pear  in the course of a half hour.   The  operator's
hands and nails should be cleansed with  soap and
brush previous to  this treatment.
   127.  Systemic  Results  of Massage.—It  has been
noted that  massage of the abdomen increases the
urine in both  its solid and liquid constituents.   Mas-
sage of the  lumbar region in the back entirely fails
to produce  this result.  Massage of the  limbs also
* Pouloubrouski— Bull Gen. deTher., Oct. 15, 1889. 
46
increases  the  amount  of the  urine.  This  fact  has
been demonstrated in experiments upon dogs.  The
hind  legs  were  massaged in these cases and the
quantity of urine eliminated rose during the first few
minutes to two,  three and five times the usual quan-
tity.   Various  precautions, taken  to  avoid  error,
showed that  the increase  was due, not to  the in-
creased quantity of the venous blood brought to the
kidneys, but to certain component elements.   The in-
crease of  urine  lasted only a few minutes, although
the massage might be continued for a considerable
time.   Bum* supposes the exciting cause to be the
fatigue products of the muscle.   If, after exhausting
the capacity of massage for producing  this increase,
the muscles of the limb were tetanized for a few min-
utes, massage would again result in an increased flow.
In the elimination of fatigue products we have,  per-
haps, one  of  the most important results of general
massage.   Among the Sandwich Islanders  when  a
swimmer  is seized with cramp or exhaustion  in the
water, his comrades gather about, sustain his weight,
and by passes of their hands over  his  limbs restore
his lost vigor.
  Increased electrocontractility is  produced  in tiie
muscles by massage;  that is, a weaker current  will
produce a contraction  after its use.
  Diminished circumference of the limb treated has
been noted by Eccles f and by Graham,| a difference
of three-fourths of  an inch having  been obtained in
the circumlerence of the thigh after ten  minutes of
deep kneading.  An increase of general temperature,
amounting to .6 to i degree F., has been reported:
also, increased temperature in the limb  massaged.

 - *Buin. Ztschr f. Klin Med., 1889, XV., p. 248.
  1 Eccles—1. c.
  t Graham—Treatise 0:1 Massage, New York, 1884. 
47
  Massage increases absorptive power in the peri-
toneum, and v. Mosengeil * has shown  that lymph
and waste products  can be forced out of a joint by
its use.    '7
  Improved appetite, digestion and assimilation are
common results of massage.   An increase in weight
is frequently observed,  and sleep is also more restful
after its application.
  To recapitulate—massage  may be  used  for the
assistance of  the venous circulation  in stasis or
hyperemia, such as is found  in cases of weak heart
and  in  local congestions and  inflammations.   Mas-
sage may be used to dissipate oedema or  lymphatic
engorgement, such as is  found in the various forms
of dropsy, the earlier stages of inflammatory swelling
and the more common  water-logged conditions char-
acterized by excessive fat.   Massage may be used
for the removal of fatigue products in  conditions of
overwork, and in no other class of cases is its efficacy
more promptly shown.  Massage has also apparently
a directly stimulating  effect upon muscle fibres, in-
creasing their  contractility.   Percussion has further
a  directly stimulating effect  upon  the activity of
nerve cells.   It is apparent that in massage we have
a stimulating mechanical agent which can be made
of the highest  practical value in  neuresthenia, the
muscular weakness of convalescence and the debility
of chronic diseases of the heart,  kidneys and liver.
It  is  applicable  also  to surgical injuries, such as
bruises, sprains,  fractures, the muscular weakness of
club-foot, lateral  curvatures and the like.
♦v. Mosengeil Arch. f. Klin. Chir., 1876, XIX., p. 428. 
 
Review Questions.
               § I  The  Motions of Massage.
 What terms are employed in descriptions of massage...........................1  1
 What is meant by  uperticial massage ..................................................  2
 In how many ways may superficial massage be performed ?  What is
    the first method ...............................................................................  3
 Where Is the first motion of superficial massagei used?  How may
    you modify this motion.....................................................................  4
 What is the second motion of superficial massage  ...........................  5
 Where do you  use the  second motion of superficial massage?
    With what  precautions  ...................................................................  6
 What important rule is to be observed in superficial massage ...........  7
 Where do you employ deep massage?  How many methods ............  8
 Where do you use the first motion of deep massage ...........................   9
 What object is accomplished by this motion  .......................................  10
 What part of the hand is employed in this motion.............................  11
 What is the position of the hand  ........................................................  12
 In what does the motion consist  .....................................................  13
 What essential  rule is to  be observed in this motion............................  14
 Where do you use the second motion  of deep massage.........................  IS
 What parts of the hands are used in  this motion................................  16
 What precautions must be observed in abdominal massage.................  17
 What is the object of this motion in abdominal massage......................  18
 What is meant  by effleurage.................................................................  19
 Where do we use effleurage...................................................................  20
 Where do we use two hands?  Where, one...........................................  21
 How should effleurage be applied..........................................................  22
 What is the object of effleurage?  What i3 meant by tapottement.....  2?
 What part of the hands are used in manual percussion ......................   24
 Where do we use the hollowed hand   ..................................................   25
 What are the advantages of this variety of tapottement ....................  26
 Where do we use the finger tips or the ulnar border ...........................  27
 What is the position of the hands in these motions  ...........................   28

                  II   General  Massage.

 What is meant by general massage ...................................................... 29
 How is  the patient prepared for general massage ..............................  30
 What preparation does the operator require ....................................... 31
 What additional precaution should be taken by the operator............... 32
 What can you say of the order of  procedure in general massage.......... 33
 What time is to be given to the different parts ...................................... 34
 Describe massage of the fingers............................................................. 35
           ......hand............................................................... 36
 What is the arrangement of mnscles in the forearm?  How  do you
   take hold of the forearm ................................................................ 37
 What motions do you use In massage of the forearm?  In what order 38
What are the muscles of  thearm?  Where situated............................. 39
How do you grasp the arm?  What motions do you use  ..................... 40
Where is special pressure made in effleurage of the arm....................  41
What is the muscle of the shoulder?  Origin and insertion ...............  42
What motions are used in massage of thedeltoid  ................................  43 
How is effleurage of the deltoid managed  ............................................. 44
How do you prepare the l;ack for manipulation  ..................................... 45
What motions are  used in massage of the back ..................................... 46
How is friction of  the hack  performed?   What is the  position of
    the hands in transverse friction.....................................................  47
How is longitudinal friction of this part best performed .......................  48
Why is this method of  friction difficult..............................................   49
What precautions will be required if the skin is moist   .................  .  50
Why are the gluteal muscles important..........................................  51
What motion is used in massage of the gluteal region.......................  52
How do you grasp the thigh   ................................................................ 53
What motions are  used in massage of the thigh.....................................  51
Where isspecial pressure to be made in effleurage of the thigh  ............  55
How do you grasp  the  le^?  What motions are used .............................  56
The peculiarities of  effleurage jpon the leg ..........................................  57
Caution to be observed in all effleurage.................................................  53
Motions used in massage of the foot ...................................................... 59
How is effleurage of the foot performed.................................................  60
The general order of procedure in  massage of the extremities..............  61
The order of procedure in abdominal massage.......................................  62
Time given to the abdomen i a general masage.....................................  63
How do you reach the colon in abdominal massage   .............................  64
Exception to the rule for centripetal effleurage...................................... 65
When may contrifugal e.Tleurage be useful............................................  66
Object of centrifugal effleurage  ............................................................. 67
Therapeutic application made of this motion .......................................68
Uupleasant  symptoms which may foilow  general massage?   How
    explained  ................................................................      .......  69
How can these unpleasant results be avoided..........................................  70
Condition of the patient after successful general massage.......................  7i
Class of people apt to bear general massage badly...................................  72
Precautions to be used in giving general massage to  fat  people...............  73
The usual  length  and frequency of treatments  in  general  mas-
    sage ? How combined......................................................................  74

                       III   Local Massage.

When do we employ massage  of the head...............................................  75
Motion used in work upon the scalp?  How managed   ..........................  76
Precautions required in massage of the scalp ......................................  77
Position assumed by the patient  .........................................................  78
Pathological conditions in the .scalp relieved by mas sage.....................  79
Time occupied by massage of the scalp?  How often is  the treatment
    repeatede...........................................................................................  go
Other motions combined with  massage of the scalp........................!! "  81
Direction taken in effleurage of the forehead and face........................"  82
Position of the operator in massage of the neck..................................    83
Positions of  the patient where the neck is massaged from behind!!!!.     84
Motions used in massage of  the neck.............................................!!!!!.    85
How is effleurage of  the neck performed...................................!...........  86
Objects of effleurage At the neck  .............................................."!!'!.......  87
How is the external jugular vein  reached............................................  88
The internal jugular...............................................................!..!!............  go
Ppits affected byeffleurage over the external jugular...................!..........  an
Parts affected by effleurage over the sxternal jugular ..........!...............  91
What can you say of Geast's method of neck massage........................  99
Weiss's  method?    In what cases is this method used.......................  93
How may a person apply neck effleurage to himself..................7.........  94
Disagreeable symptoms sometimes accompanying  neck massage?.....
    Bow can it be avoided........................................................,_        gg
Accident in the course of its admistration ...........................!!."!.............  98
For what conditions is neck massage used............................"..........  gS
Duration of treatments and how often should they be repeated..........  oa
Conditions relieved by self-application ...................................     .........  qg 
Whendo we use massage of the breast.................................................. 100
Motions used in massage of the breast..................................................  101
How is effleurage of  Ibe breast performed ......................................... 102
Duration of treatment? When repeated  ............................................ 103
Contra-indications of breast massage.......................................   104—105
Precautions required in the administration of breast massage?  How
    can you become skilled.................................................................... 106
In what conditions is massage of the abdomen useful..........................  107
Describe in detail the motions of abdominal  massage........................  108
How much time may be used in its application and how often should
    it be repeated............................................................................ 109
In what cases should abdominal massage be avoided........................... 110
Unpleasant symploms from abdominal massage?  How can  these
    be  avoided ...................................................................................... Ill
In what class of cases i3 pelvic massage sometimes used....................  112
Positions of the hands in pelvic massage.............................................  113
The usual duration of treatments in pelvic massage...........................  114
When  is massage of  the coccyx useful................................................  115
Position of the hands in coccygeal massage  .......................................  116
Motion used?  Precaution to be observed.............................................  117
Leugth of treatments?  Frequency of repetition.................................  118
What does massage accomplish in surgical injuries.............................  119
How often should it be applied?  For how long................................... 120
The essential elemant of surgical massage.....................................  121
How is massage applied for "Writer's Cramp"?   How often?  For
    how long..................................................................................122-123
In what affections of the eye is massage sometimes used.................... 124
How is massage applied to the eye.....................................................  125
When  is  massage of the eye contraindicated?  Precaution  to
    observed  ...................................................................................... 126
Name  some of the systemic results of massage?  How  is the  increased
    excretion of urine  accounted for?  What is meant by increased elec-
    trocontractility?  What causes diminished circumference in  the limb
    massaged? 
 
     The   Nightingale

                 A WEEKLY JOURNAL,

  In the  Interests  of Good Nursing
                     EDITED BY

           Sarah E. Post, M. D.
                  GRADUATE OF THE

       Bellevue  Hospital  School
              PUBLISHED EVERY SATURDAY BY

The Nightingale  Publishing Company

            13 West 42d St., New York.
82.OO F»er Year.
  "I am much pleased with the paper."—L. M. Masten, Supt.
Nurses, General Hospital, Buffalo, N. Y.

  "The nurses here always read The Nightingale with much
interest."—Florence Hutcheson, Supt. Flower Mission T. S.,
Indianapolis, Ind., Nov. 14, 1890.

  "I wish to thank you for the valuable information contained
in your paper which has  been a  great  help to me in many
ways."—M. B. Brown, Supt. T. S., Mass. General Hospital,
Boston, Mass.

  "I could illy afford to do without your paper's helpful hints
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help which The Nightingale brings in her weekly visits."—
H. Florence Montrose, Supt. Wis. 7. S. National Home,
Wisconsin.
              Sample Copy, Free. 
MASSAGE   PRIMER
                       BY
         SARAH  E.  POST, M.D.
Lectures before the Training Schools for Nurses connected with Bellevue Hos-
       pital, Ml. Sinai Hospital, St. Lukes Hospital, and Charity
                      Hospital, New York.
  This is not a compilation of cases, but constats of solid instruction arranged
for use as a text-book in three parts.  The first is devoted to a description of
the motions of massage, givin ; the various stroking, kneading and percussing
motions. The second is devoted to general massage, giving the minuter de-
tails in regard to the management of the patient, length of application, the
peculiarities of patients, references to the Weir Mitchell and Playfair treat-
ment, etc. The third is devoted to local massage, and is in itself worth the
price of the book even to the physcian or to skilled manipulator, embracing,
as it does, a synopsis of the literature of the subject, including dosage and fre-
quency of repetition required to effect cure.  Among the subjects treated are
massage of the neck, breast, abdomen, massage for writer's camp, and pelvic
massage, including massage of the coccyx.
        FROM PHYSICIANS AND  THE MEDICAL PRESS.
  "I have Taylor and others on massage, but when I read your
Primer I said, 'There is massage  for every day use.'  I think
no one can appreciate the  difference in books better than the
country doctor who has continually to  focus his discrimination
having to depend  upon them alone  to  keep abreast with the
times."
  "I have just read your little volume on massage and am de-
lighted with it.  I think it is really the best manual I have seen;
it contains a great deal of information, compressed into  such a
small space that perhaps some of yonr readers will not perceive
how much there is."
  "Just what one wants to give a nurse enough information on
massage, to enable  her to obey directions intelligently."—Med
teal 7 itnes and Register, Philadelphia.
  "This little volume is intended solely for the instruction of
nurses; but within its fifty pages it contains more valuable in-
formation on the use of massage than any other book  on the
subject with which we are familiar.  Not only is it replete with
valuable  instruction and sound common  sense, but, what is
more rare, it does not contain one unnecessary  sentence.—
N.  V. Med. Record.
  Second Edition.  With Seven Original Photo-Plates.  Price, One Dollar.
                Sent, postpaid, on receipt of price, by
THE NIGHTINGALE  PUBLISHING CO., 13 W. 42d Street, New York. 
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                ----BY----
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   This book  is the first of a series of Manuals and
Text-books published under the direction of the Nurs-
ing Record, London.  It comprises the most recent in-
formation  in regard to bacteria,  and their relation to
suppuration, together with the present practice in anti-
sepsis and the treatment of wounds.  Accurate directions
are given to the nurse in regard to her duties both at
and after the operation.  No nurse who has been away
from her hospital for a number of years can afford to be
without some such book.
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