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The Meaning of Massage and It’s Technique

The Meaning of Massage and Its Technique By Dr. Emil A.G. Kleen

“MASSAGE means a manipulation or handling of the soft tissues by movable pressure in the form of stroking, rubbing, pinching, kneading or beating performed with a therapeutic aim. This is generally applied by hand, but can, of course, also be given by means of instruments and apparatus of different kinds.” Shown at left, abdominal massage or abdominal kneading. – Dr. Emil Kleen, 1888

Editor’s introduction: This excerpt is from Dr. Kleen’s 1921 book, Massage and Medical Gymnastics. Dr. Kleen was a Swedish physician whose first book, Manual of Massage, was published in 1888. The 1921 book is essentially the same book as the 1888 title, with some revision and additions. Dr. Kleen’s work was translated into several languages, but he wrote only in Swedish. This final edition of his book was printed shortly before his death in 1921. The book was intended to support the continuation of manual therapy work that was so successful during World War I. Dr. Kleen, along with other noted physicians of Europe, believed that manual therapies were an important part of medical practice. His writing brought massage to the awareness of many other physicians. He was a staunch critic of lay practitioners. He and most other physicians believed that massage was only valuable and inscrutable when performed by the physician or under his direction. The material that follows is from the first chapter of the book. His argument distinguishing between massage and gymnastics was a recurrent theme in his writing, but an important one that drew much criticism. It becomes obvious that his distinction is important when it comes to applying massage or gymnastics to specific medical conditions. This excerpt is in its original language taken directly from his writing. The article tells us what is and is not massage, the attributes of a masseur, to develop your own style of doing massage, describes the four classes of massage manipulations (strokes), that the hands are the best tool for massage, but that vibrators and other tools are helpful aids, the strength needed in applying massage to various conditions, the length of a session (“séance”), what lubricants are useful and it demonstrates with photos various techniques used on specific medical conditions.

To limit accurately the term “massage” it is necessary in the first place to distinguish it from medical gymnastics, which is treatment by means of exercise of the organs of the motor apparatus. At a first glance at these definitions confusion of ideas seems unlikely. They have for long been denoted by different terms, and their existence has been distinguished both by the general public and by doctors. But the two methods of treatment have several points in common; they must often be used together therapeutically and are often performed by the same craftsman. Strangely enough the idea had never to my knowledge been definitely and clearly defined in literature before I formulated the two definitions, and pointed out the difference in my “Manual of Massage” in 1888. In a concrete case the differences stand out so sharply that one can scarcely understand that any one, especially any one practising massage and gymnastics, should have been unable to grasp them. One can, for example, massage an infiltration or a hæmatoma, since they are in a sense soft tissues, but it is impossible to apply gymnastics to them, since they are not organs and certainly not organs of movement. A muscle, on the other hand, can be treated both by gymnastics and massage: in the latter case it is treated not as an organ, but simply as a tissue (e.g., in getting rid of an infiltration by friction); in the former case it is used as an organ, and as such must act by shortening and lengthening, or by performing static work to maintain a position. The fact that massage by getting rid of the infiltration raises the muscle’s functional power, and in this has the same aim and to some extent the same effects as gymnastics, as well as the fact that gymnastics used along with massage helps to get rid of the infiltration, in no way contradicts the legitimate distinction between these two methods of treatment, which coincide neither in their character nor in their effects. In contrast to gymnastics, massage is not treatment by exercise. Opinions may differ as to considering passive movements exercise-treatment for parts of the motor apparatus other than the joints. Passive movements, however, are the part of gymnastics most closely allied to massage. Positions, too, are exercise of the motor apparatus, especially for muscles and nerves, and obviously belong to gymnastics and not to massage.

We must also distinguish from massage some manipulations which even gymnasts cannot say belong to gymnastics, but which are sometimes assigned to massage. Static pressure, whether it can be reckoned in orthopædics or not, can under no circumstances be included in that division of physical therapy which is called massage. Similarly one must exclude from massage those manipulations which are performed in order to replace an organ or part on an organ from an abnormal position, e.g., taxis in case of hernia, manipulations through the abdominal wall to release an invagination or volvulus, replacement of the uterus, etc. Some obstetric manipulations I also consider outside the province of massage, Kristell’s method of expression of the fœtus, Crédé’s method of detachment of the placenta. For my own part neither do I regard as massage the strokings by which in a skin wound one can get rid of the air in traumatic emphysema. Lastly, I also exclude from massage the method (in more than one sense heroic) employed in England by Teale, Sir William Fergusson and others, of causing detachment of parts of the contents of an aneurysmal sac by kneading, with consequent embolism of the peripheral arteries, leading to complete consolidation of the aneurysm. Lastly, we cannot consider as massage manipulations for the introduction of medication, e.g., rubbing which is performed for the inunction of mercury.

The technique of massage
is peculiarly important, since its effect depends on the method in which it is performed. But massage as an art is easy, requiring less practice and skill than many other of the mechanical tasks in which every one of us must have a certain skill, e.g., the use of the laryngoscope or the catheter, the common typical operations, etc. For those who from the standpoint of anatomy, physiology, and pathology know what is present in individual cases, the different manipulations come as it were of themselves. In these there is the greatest difference between the scientifically trained and the uneducated masseur. The former has during his years of medical study travelled over most of the ground which leads to becoming a good masseur; for the rest he only requires comparatively short study, normal upper extremities of average strength, hands neither too thin nor too small, and some aptitude for mechanical work. Further, it is a great advantage to watch or help a skilled masseur for some time. One thus acquires the technique more easily and surely than in any other way, and, besides, gains more quickly knowledge which belongs especially to the masseur and can only be slowly obtained from one’s own experience. I would emphasise, on the other hand, that it is never worth while to follow slavishly a definite example in technique, but every one must work out his own method, which soon becomes as individual as his handwriting. It is obvious that manipulations which have quite the same effect on the patient may be performed in many different ways by the masseur. A good masseur thinks less of the way in which he moves his hands at his work than of the tissues he is working upon, and the quality of his massage depends to a very great extent on his knowledge of their condition.

For such knowledge, besides the above-mentioned studies, the power of palpation is necessary; skill in this respect is the masseur’s most difficult task, and can only be acquired and maintained by practice. (The examinations which specially concern the masseur are mentioned later.)

The manipulations which are met with in massage have been classified in very different ways. Many of the scientific exponents of massage are, however, fairly well agreed in distinguishing four different classes of manipulation, which are generally denoted by French names, and are: –

1. Effleurage = Stroking.
2. Friction = rubbing with pressure.
3. Pétrissage = pinching, rolling, kneading.
4. Tapôtement = blows, slapping, hacking, beating, clapping, shaking, vibration.

Effleurage (Figs. 1-5) consists of centipetal strokings performed with varying strength generally over a large surface of skin, and with a large surface of hand; with the flat hand, with the ulnar or radial portion of the hand, with the thenar eminence, with the base of the hand, with thumb and forefinger, generally with one hand at a time, but sometimes with both hands together (as when a limb is grasped). Effleurage is a form of massage very frequently used and has a therapeutic aim which constantly recurs in practice. The chief function of effleurage is to hasten the circulation the blood and lymph vessels; it is therefore often performed over the more important veins, where these are easily affected, as in the front of the neck and in the extremities. Thus in general massage (as in other forms of massage) stroking over the veins of the extremities is used in the form of long strokes from the wrist to the proximal end of the upper are, or from the fold up to the fold of the groin.In local massage also one often uses effleurage over the superficial veins to hasten the circulation within a comparatively small area. In both cases the stroking is given with very moderate pressure. Again, when one makes use of stroking to press the blood and lymph out of a whole muscle group one uses rather more strength in the manipulations. Figs. 1 and 2 show effleurage of the leg as it is performed in general massage. Fig. 1 shows the hand of the masseur gliding up over the calf and approaching the popliteal space. When the hand has reached the popliteal vein and effleurage is to be continued over the veins of the thigh, the hand is turned so that the fingers are directed to the other side of the thigh (Fig. 2), in order to continue the effleurage right up to the groin without risking coming in contact with the external sexual organs.
Fig. 3 shows a method of performing effleurage over the front of the forearm, the thumbs gliding over the outer side, the other fingers over the inner side of the patient’s are, at the same time going over the large veins in that situation.

Fig. 4 shows another method of performing effleurage of the forearm. In this the tips of the fingers are towards the outer side of the arm while the base of the hand moves along its inner side.

Fig. 5 shows effleurage over the shoulder-joint, e.g., after a dislocation. The masseur, with bothhands flat, performs a circular stroking movement, one hand passing over the front, the other over the back of the shoulder with moderate speed and strength on both sides.

Friction is rubbing with pressure, generally performed over small areas, with the palmar surface of the last phalanx of the thumb or of the three middle fingers, but also may be performed in other ways, e.g., with the base of the hand or with the whole palm. Friction is used chiefly to hasten retrogressive changes in inflammatory products, infiltration’s and exudations, to press into the outlying lymphatics the disintegration products, and so to promote their absorption. The direction of this manipulation is therefore unimportant, but it is generally necessary to use firm pressure. This is generally possible, but not always. When friction is performed over the eye or over inflammatory products in the abdomen and pelvis, it is obvious that it must be performed with very moderate pressure.

Fig. 6 shows friction as it should be performed for rheumatic infiltrations of the neck in the upper part of trapezius or occipitalis. The masseur presses in on the affected parts, performing a small movement with the apposed tips of his three middle fingers.

Fig. 7 shows friction performed by the thumb on the knee-joint over an infiltration in its capsule, an affection called by Swedish doctors “capsulitis.”

Fig. 8 shows friction performed over the left supraorbital nerve for rheumatic interstitial neuritis. It is a small matter whether one prefers to use the palmar surface of the last phalanx of the thumb or of the three middle fingers.

Fig. 9 shows friction with the palmar surface of the last phalanx of the middle finger above and through theeyelid for opacities in the cornea. The fingers perform a small movement from side to side with as much pressure as may be given without risk.

Fig. 10 shows friction in a case of sciatica due to muscular inflammation, performed with the palmar surface of the last phalanges of the three middle fingers, over the gluteal muscles, which in these cases are often the seat of rheumatic infiltrations.
Fig. 11 shows friction performed with the base of the hand in a case similar to that shown in Fig. 10. It is a form of technique seldom seen but not objectionable.

Fig. 12 shows friction with the base of the hand over infiltrations in the back muscles. The remark in reference to Fig. 11 applies also to this.
Fig. 13 shows friction over rheumatic infiltrations in the back muscles given with the whole palmar surface of the hand, a method less often used but very useful in cases of widespread infiltrations.
It is obvious that since all massage manipulations vary in form and may be performed in different ways with the same effect, and since effleurage and friction in particular have to some extent the same object, in that they promote absorption, there must be various transition forms between the two. But generally speaking, effleurage is performed over a large surface of skin and less pressure is used than in friction.

Pétrissage consists of rolling, kneading, and pinching. Its physiological effects resemble those of friction in that it promotes absorption of the products of inflammation, and those of tapôtement in that it is a form of muscle stimulus. These react to a pinch as to a blow by a local contraction and thickening.

Fig. 14 shows pétrissage over the upper border of trapezius, which is a favourite situation for rheumatic muscle infiltrations. The masseur grasps the muscle between his thumbs behind and his fingers in front and lets his hands perform a series of pinching or wringing movements.
Fig. 15 shows pétrissage of the forearm as it is usually given in general massage. The masseur holds one hand on the front, the other hand on the back of the forearm, and kneads the muscle masses by a movement of one hand against the other.

Fig. 16 shows the same procedure on the upper arm. By their movements against each other the masseur’s one hand works on the flexors, his other on the extensor muscles.
Fig. 17 and 18 show pétrissage of triceps on the upper arm. In Fig. 17 the masseur holds his thumb on one side, his fingers on the other side of the muscle mass; in Fig. 18 the manipulation is performed by means of pinchings between the four fingers and the base of the hand; the latter form is much more seldom used than the former. Altogether, pétrissage is a form of massage less often used than effleurage and friction. Used as in Figs. 14 and 17, the manipulation has a diagnostic as well as a therapeutic value, since one can in this way palpate and recognise muscle infiltrations.
   
  
 
Tapôtement (Figs. 19-22) consists of manipulations which aim essentially at mechanical stimulation of muscles or nerves; these manipulations are all characterised by their blow-like nature and are named as already mentioned, hacking, beating, shaking, vibration* [See footnote below]. We work upon the skeletal muscles by beating them all over with the closed fist, by hacking them at right angles to their long axis with the ulnar border of the hand (Fig. 20), or, especially in the case of small thin muscles, as the extensors of the forearm, flicking them with the dorsal surface of the fingers generally held slightly apart (Fig. 21). By shakings performed from side to side with one hand on each side of the patient’s abdomen we affect both the muscles of the alimentary canal and its nerve elements. By hackings or vibrations over the head or spine we can mechanically stimulate the cerebro-spinal centres within their bony covering. By chest clapping we stimulate the vagus and consequently produce slowing of the heart-beat and pulse. We affect nerve trunks by percussion or vibration along their course, and lastly, we can stimulate the nerve endings in the skin by different kings of tapôtement, e.g., by blows with the flat hand or with different instruments.

Fig. 19 shows back hackings in standing position as performed by Swedish gymnasts; tapôtement given with the ulnar border of the masseur’s hands, the fingers being parted.
Fig. 20 gives a picture of tapôtement of the back in general massage. The hands are slightly supinated and strike the back with part of their dorsal surface. The hands go up and down several times on each side of the spine. Tapôtement is often given also over the spine.

Fig. 21 shows a method of performing tapôtement on the dorsal surface of the forearm. The masseur, with fingers held apart, flicks the thin extensors of the forearm with their dorsal surface.
Fig. 22 shows a method occasionally used by giving vibrations without instrumental aid over the posterior nerves on each side of and quite close to the spine. The three middle fingers of the masseur’s left hand go
down the left side of the patient’s spine, the three middle fingers of his right hand down the right side, giving a series of small quick blows. This manipulation requires much practice.

Generally speaking, massage as a whole is performed best by hand, and no instruments exist or can ever be produced with which one can, even approximately, perform the various manipulations that go to a massage séance as well as by the hands.

But it cannot be denied that in some cases one may with advantage make use of instruments. Certain forms of tapôtement and especially vibrations are performed much more smoothly, quickly, and strongly by means of instruments than by hand.

A great number of cheap, efficacious and durable vibrators are now in the market – the “Veni-vici vibrator,” the “Auto-vibrator,” the “Medical vibrator,” etc. Of Zander’s well-known and ingenious apparatus most are concerned with gymnastics, but several with massage, and among the latter those which aim at vibrations are, beyond a doubt, those which best fulfil their aim.

Some masseurs use india-rubber balls provided with handles and long or short levers. An instrument for tapôtement looks like a thimble with such a ball at its point. At one time a “palate” was used, a round flat wooden slab on a lever with a handle, to stimulate the skin by repeated blows. At some of the Swedish seabathing places different kinds of seaweed, chiefly Fucaceœ are used for the same purpose.

Some masseurs make use in other forms of massage of small wooden wheels, straps, brushes, gloves, sponges; the latter or metal wheels are used at times to give electric treatment along with massage. Most doctors who give massage themselves make use of their hands only, except in the case of instruments for vibration.

The strength of the manipulation is, of course, a very important factor, and varies widely with the different therapeutic aims and the different morbid anatomy underlying the special case. For instance, if one is dealing with a fresh sprain, and massage has chiefly an antiphlogistic aim, one sets to work, especially in the beginning of the treatment, with quite light effleurage; if one has before on an extensive hard œdema with a plastic tendency, effleurage as well as friction is firm; if the question is to get rid of already partially organised exudations round a joint after a joint inflammation, one must use hard friction; again, if it is perityphlitic (“appendicitis”) or parametric exudation, one must exercise unceasing care, remembering the proximity of the peritoneum and the danger of a new inflammatory process, etc.; all matters which we shall deal with later more in detail, but which in individual cases must be left to the good sense of the masseur. With beginners the commonest fault is to be too hard-handed, but prefessional masseurs* [See footnote below] often tend, on the contrary, to be too superficial. I would especially call attention to the erroneous statement of certain authors that massage should never be done hard enough to produce marks of discoloration of the skin, and that every such mark is the “fault” of the masseur. This may be true of general massage and some other cases, but very many of the cases for which massage is suitable (e.g., many chronic joint affections) need such strong massage that marks are necessarily caused. They are of little or no importance and soon disappear.

The length of the massage séance is also important, but there can be no general rule. Several points must be considered in deciding what is enough, and, in the first place, the nature of the lesion. Often in this, as in the strength of the manipulation, one must be guided by the patient’s general condition, since nervous, sensitive patients can stand neither a long séance nor hard massage. In these cases one must begin the treatment gently and with a short séance, gradually increasing the strength of the massage and its duration. For local massage generally a quarter of an hour is suitable. General massage (which is usually done by some one other than a doctor) takes at least half an hour, often more.

In certain acute cases, and especially when used as an antiphlogistic (by means of effleurage), as, for example, in a recent sprain of the ankle, massage should be performed several times a day; in other cases at least twice, never less than once a day.

The masseur should from the beginning accustom himself to use both hands and divide the work equally between them. While he is still new to the work, like other mechanical workers, he squanders his strength and becomes easily tired, but he quickly learns to obtain the greatest possible effect, and can do much more work than seemed at first possible.

The masseur should never make use of narcotics to prevent or remove pain which he must occasionally cause. The pain is seldom great, and there are other means of counteracting it. Latterly hypnotism and hypnotic suggestion have begun to play a part, in many cases with wonderful success; but I can offer no opinion on the subject, as I have never attempted it.

Massage is almost always given directly on the skin, since in giving it over clothing, as is done by some masseurs in certain cases, one loses technical accuracy. Regard for modesty in a doctor’s consulting room can be carried too far, to the detriment of more important considerations, and also to the extent of producing the painful self-consciousness it aims at avoiding. One takes care, especially with women patients, not to uncover more than need be uncovered, and not to uncover at one time more than the part about to be massaged.

Most masseurs make use of some lubricant to make the patient’s skin soft and smooth. This is often a necessity, especially for firm effleurage, as otherwise one cases pain by dragging the hairs of the skin, and may irritate the glands of the skin and so cause acne or boils. Different skin lubricants may be used: glycerine, vaseline, lanoline, lard, “cold cream,” olive oil, cocoa butter, etc. Glycerine I definitely condemn, since its strongly hygroscopic properties make it irritating to the skin; vaseline irritates somewhat. Liquid oils are troublesome to handle. Solid cocoa butter is better, but it has a fairly strong smell. On the whole it seems to me that lard should have the preference.

Some masseurs use only talc or other powders. In general massage this often seems to me most comfortable for the patient. If, however, the masseur has the good fortune to possess really dry hands he can give general massage without either powder or lubricant.

For deep effleurage, especially over the forearms or legs, it is sometimes necessary to shave the part once or twice a week, otherwise “pimples” may arise.

The masseur’s hands must be carefully washed immediately before and after each séance; the nails should not be too long, and no rings should be worn.

There are many different forms of massage according to the anatomical conditions. Generally massage is local and is applied only to a small part of the surface of the body, but it may also be applied to the greater part of the body, and is then called general.

  The different forms of local massage are described later in their proper places; for practical reasons, and to make the study of the physiological and general therapeutic effects mentioned in the next chapter easier for the reader, we give here a short description of the technique of massage of the front of neck and of the abdomen as well as of general massage.

Massage, or rather effleurage, of front of neck * (5) aims at hastening the circulation in the area of the

blood vessels concerned, which are for this purpose favourably situated anatomically. With the palmar surface of each hand pressed against the corresponding side of the patient’s neck, and with both hands together, the masseur passes his hands several times from above down with rather firm pressure over the jugular veins in as much of their course a possible, at the same time avoiding pressure on the hyoid bone or larynx (see Fig. 23.)

Fig. 24 shows the method of giving effleurage of front of neck used by Höffinger and others, standing behind the patient, which seems to me more comfortable and better than standing in front. The illustration is not quite satisfactory, as it gives the impression that the strongest pressure is given near the mid-line.

In case of necessity Gerst allows the patient himself to massage the front of the neck, using first one hand and then the other, with the thumb on the corresponding side of the neck passing down over the common jugular vein; the other fingers work over the veins of the other side of the neck.

Effleurage of front of neck is performed with constantly repeated stroking for about ten minutes at a sitting; the number of sittings advisable in acute cases may be as many as five or six a day.

In such cases a lubricant is useful. Massage of front of neck is preferably given by a doctor, but may be entrusted to others as Gerst has shown.

Abdominal massage or “abdominal kneading” aims at manipulating the alimentary canal through the abdominal walls, and is generally given (see later) for chronic constipation. The masseur, holding his fingers hyperextended, place the palmar surface of the three apposed middle fingers over the part which is for the moment to be massaged, with moderate force presses in the abdominal wall,
and, by means of small circular manipulations with steady pressure, kneads or rubs the corresponding part of the alimentary canal, between the anterior and posterior abdominal walls (see Figs. 25,26). The patient’s skin moves with the masseur’s fingers and a lubricant is unnecessary. During this manipulation the masseur keeps his hand fixed in slight dorsal flexion at the (upper and lower) wrist joint, and in the sitting position the movement is divided between the elbow, shoulder, and hip joints. One hand is used at a time, the right and left moving alternately.

In massage of the stomach this manipulation is applied over the gastric and left hypochondriac regions, but reaches only a small part of the organ if it is approximately normal in size. If the stomach is dilated it is to that extent more within reach of massage. By performing the above manipulation more staccato (more after the manner of tapôtement, although the fingers do not leave the abdominal wall), for example, over an atonic or dilated stomach, one can give a stronger mechanical stimulus than by means of the smoother pressure to the non-striated muscle and so produced contraction. Among Zander’s apparatus there is a vibrating pellet which vibrates from side to side; by leaning against this with the part of the abdomen required the patient receives a forcible shaking over the stomach and bowels.

In manipulating the large intestine one begins over the cæcum, then going over the ascending, transverse, and descending colon and sigmoid flexure down to the symphysis pubis, paying careful attention to every 1/4 cm. of bowel, except those parts (the hepatic and splenic flexures) which for anatomical reasons cannot be reached. The small intestine is got at by similar manipulations over the umbilical and lumbar regions. In very sever cases of chronic constipation one should insist on treatment twice a day. The effect of the treatment depends essentially on the manipulation being performed long enough on each part of the bowel before the fingers are moved on to the next; the whole séance should occupy at least fifteen minutes.

To empty the contents of the large intestine into the rectum one can afterward with one hand – or better and more strongly with one hand applied over the other to strengthen it, only one hand coming in contact with the patient’s skin – perform stoking over the large bowel, especially over the transverse and descending colon and sigmoid flexure. One can also attain this object by placing the hands one over the other (see Figs. 27 and 28), and constantly moving first the under, then the upper hand a little at a time and without for a moment relaxing the pressure on the bowel. In this one does not press directly downwards all the time, rather upwards, but the whole procedure, which ends over the symphysis pubis, is extremely effective in emptying the contents of the large intestine into the rectum.

In ordinary cases there is no great necessity for the doctor to perform the abdominal kneading, and no danger in leaving it after some instruction to non-medical workers, although it then seldom gives such good or rapid results even when performed in the simple and effective manner above described. It is noteworthy and interesting that, in spite of the extreme simplicity of abdominal kneading and the eagerness of my pupils to learn it, I have great difficulty in getting them to do it properly; and I understand more readily since I have begun to teach these subjects how it happens that so few masseurs can perform the “miracles” so easily obtained in severs cases of chronic constipation. I will refer again to this subject at the end of the next chapter and in the chapter on Diseases of the Alimentary Canal and Abdomen.

The above-described simple technique is that which for nearly a quarter of a century I have found most effective while experimenting with different manipulations on a large number of patients with chronic constipation, and I think from my experience I am giving the reader good advice when I beg him not to waste time on other less effective or quite ineffective manipulations by whatever masseur they are recommended. Many classes of manipulations, so warmly recommended in some quarters, with circular strokings round the umbilicus, with pressures over the cœliac plexus (half-way between the ensiform process and the umbilicus), and over the splanchnic plexus (half-way between the umbilicus and the symphysis pubis), with sacral beating, etc., are empy “ornaments,” or at least of very doubtful and certainly subordinate value, and one only wastes time over the. Stroking over the colon, strongly performed with one had, or with one hand over the other, are certainly capable for the moment of sending the contents of the bowel into the rectum, and thus promote, also for the moment, a more immediate action. But this is not the chief aim of the treatment (see next chapter), and the same result is obtained by the manipulations already recommended, which in all their simplicity, when conscientiously performed, gain their end with certainty, although, in sever cases of chronic constipation, often not till after several months’ treatment.

General Massage * (6), during which the patient lies undressed in bed (and should always be massaged by some one of the same sex), comprises the greater part of the body, begins with the extremities, and on the whole goes from the periphery towards the centre. The patient lies on the back except while the back is being massaged, when he lies on his face. General massage is given by my pupils as follows: –

The masseur begins with the upper extremity, using his hands as follows: – With his opposite (e.g., left) hand he grasps the patient’s (right) hand, and with the whole palmar surface of his other hand performs effleurage over the superficial veins of the front and radial side of the whole are, from the wrist upwards, namely, over the cephalic, basilic, and median veins and their anastomoses (Figs. 3 and 4). After half a dozen such strokes he begins treatment of the forearm by compressing by deep effleurage with one (right) hand the muscles on the anterior surface, and then with the other (left) hand the muscles on the dorsal surface. Pétrissage of the forearm follows, and, like all the manipulations, is repeated a few time. It is performed over the whole muscle mass; the masseur, holding his thumbs moderately abducted and the four fingers somewhat flexed, grasps the forearm between his tow hands, one on each side (front and back), touching it with the palmar surface, with the radial surface of the forefinger, and with the palmar surface of the thumb (Figs. 15 and 16). He then kneads with small, smooth, circular movements, which by degrees, without the hands ever leaving the patient’s skin, travel over the whole surface from the wrist to the elbow. In the tapôtement which follows he gives light blows with the fist to the thicker muscles on the flexor aspect; to the thinner extensors he gives light blows on the dorsal aspect of the forearm with the dorsal surface of the four fingers of the open hand (see Fig. 21). The muscles of the forearm are then again compressed by effleurage as described above. This finishes the treatment of the forearm. Before going on to the treatment of the upper are, effleurage over the whole are may be repeated. He compresses the anterior muscle groups with one hand, and then with the other hand treats the posterior muscles in the same way. In the pétrissage which follows he treats the anterior muscle groups by themselves and the posterior by themselves; he gets at the posterior muscles best by adducting the patient’s upper arm in front of this chest (Fig. 17). He then gives tapôtement (best with the fist) over both muscle groups, and again compresses them by effleurage. He strokes, kneads, claps, and strokes again the deltoid muscle by itself, and completes the treatment of the arm by effleurage over the whole.

Before and after back hacking one treats the muscles of the shoulder blade by themselves by giving effleurage, tapôtement (with the finger tips), and again effleurage above and below the spine of the scapular.

The gluteal regions are next treated in the same way; but many patients dispense with this altogether. The treatment of the back ends as it began, with effleurage.

With women patients we leave the chest untouched; with men one can treat the pectoral muscles and subclavius by stroking, hacking, and repeated stroking.

If special indications exist for massage of front of neck, one may suitably end general massage with this.

In general massage all the manipulations are as a rule performed with moderate strength. It is important for patients, especially those who are having a long course of it, that it should be performed comfortably, or at least without discomfort.

If the masseur has quite dry hands, he generally uses no lubricant for general massage; if not, he uses either a lubricant or talk power for effleurage.

General massage should take at least half an hour (preferably about an hour), demands little more than mere mechanical skill, and can in most cases be quite well performed by non-medical workers. The doctor in busy practice has seldom time to give it himself, and can entrust it to any trustworthy person of the same sex as the patient, after he has once given instructions for the special case.

FOOTNOTES
(1)* The French word massage may be derived either from the Arabic mass (to press), or from the Greek anatripsis (to rub).
(2)* Vibrations are, by some authors, considered as a special fifth group of manipulations. They are distinguished however from other forms of tapôtement merely by the greater frequency of the blows in a given time and by the smallness of the movement. They aim at a similar stimulation and produce similar effects. Then vibrations are given by instrumental means on mucous membranes which are difficult to get at by means of the fingers (see later) they are really a substitute for frictions.
(3)* Busy masseurs are under constant temptation to make their séances shorter and less vigorous than is really consistent with the patient’s interest, the result of simple calculation which we leave to the perspicacity of the reader, the consequence being that their work yields quick returns only in an economic sense.
(4)* Even this bench is not at all necessary, and of later years I have myself used an ordinary couch. Plinths of different kinds are used in my Institute. During all the many years which I have used massage in my practice I have used no instrument but my hands and a vibrator. This last should be in the possession of every one who makes much use of massage.
(5)* Massage of front of neck has been used in Sweden at least since the time of Ling, who mentioned it and understood its chief effects. In our days Gerst, Weiss, and others have laid stress on its therapeutic value in various inflammatory processes and hyperæmic conditions of the head (see later).
(6)* General massage has been used in the interests of health from time immemorial (especially with baths) by nearly all Oriental, as well as by several European races, and it is widely met with as a popular remedy, for example, in the islands of the Pacific. Medically it is perhaps most often used and with much benefit as a substitute for physical exercise when this is for some reason impossible. It plays an important part in the so-called Weir-Mitchell treatment. In dystrophies, “general weakness,” and chlorosis it is also of value.

General Massage * (6), during which the patient lies undressed in bed (and should always be massaged by some one of the same sex), comprises the greater part of the body, begins with the extremities, and on the whole goes from the periphery towards the centre. The patient lies on the back except while the back is being massaged, when he lies on his face. General massage is given by my pupils as follows: –

The masseur begins with the upper extremity, using his hands as follows: – With his opposite (e.g., left) hand he grasps the patient’s (right) hand, and with the whole palmar surface of his other hand performs effleurage over the superficial veins of the front and radial side of the whole are, from the wrist upwards, namely, over the cephalic, basilic, and median veins and their anastomoses (Figs. 3 and 4). After half a dozen such strokes he begins treatment of the forearm by compressing by deep effleurage with one (right) hand the muscles on the anterior surface, and then with the other (left) hand the muscles on the dorsal surface. Pétrissage of the forearm follows, and, like all the manipulations, is repeated a few time. It is performed over the whole muscle mass; the masseur, holding his thumbs moderately abducted and the four fingers somewhat flexed, grasps the forearm between his tow hands, one on each side (front and back), touching it with the palmar surface, with the radial surface of the forefinger, and with the palmar surface of the thumb (Figs. 15 and 16). He then kneads with small, smooth, circular movements, which by degrees, without the hands ever leaving the patient’s skin, travel over the whole surface from the wrist to the elbow. In the tapôtement which follows he gives light blows with the fist to the thicker muscles on the flexor aspect; to the thinner extensors he gives light blows on the dorsal aspect of the forearm with the dorsal surface of the four fingers of the open hand (see Fig. 21). The muscles of the forearm are then again compressed by effleurage as described above. This finishes the treatment of the forearm. Before going on to the treatment of the upper are, effleurage over the whole are may be repeated. He compresses the anterior muscle groups with one hand, and then with the other hand treats the posterior muscles in the same way. In the pétrissage which follows he treats the anterior muscle groups by themselves and the posterior by themselves; he gets at the posterior muscles best by adducting the patient’s upper arm in front of this chest (Fig. 17). He then gives tapôtement (best with the fist) over both muscle groups, and again compresses them by effleurage. He strokes, kneads, claps, and strokes again the deltoid muscle by itself, and completes the treatment of the arm by effleurage over the whole.

When both arms have been thus treated the masseur goes on to the lower extremities, grasps with his opposite (e.g., left) hand the patient’s (right) foot, compresses with the thumb of his corresponding (right) hand the network of veins on the dorsal surface of the foot, and with a continuous movement strokes with the palm of the same hand over the veins of the calf and the popliteal vein, following the saphenous vein with the thumb (Fig. 1). When the masseur’s hand in this continuous effleurage has reached the lower part of the femoral vein on the front of the thigh he then rotates this hand (without breaking off the effleurage which should go with one stroke over the whole limb) so that the thumb, which would otherwise be directed outwards on the front of the thigh, is now directed downwards towards the knee, and the other four fingers, which would otherwise be directed inwards on the front of the thigh (towards the mid-line of the patient), are now directed outwards (Fig. 2). By thus changing the position of the hand, when the effleurage ends at the groin the hand comes near the external genital organs without discomfort.

Treatment of the leg begins and ends, like that of the forearm, arm, and thigh, with compression of the muscles, in which he lets the thumb of the corresponding hand go on the inner side of the calf muscles, while the four fingers encircle them. With the four fingers of the other hand he then compresses the peronei, letting the thumb act in the same way over tibialis anticus. The calf muscles must be kneaded by themselves and tibialis anticus by itself. For tapôtement it is best to use the fists over the thick calf muscles.

In massage of the thigh one divides the muscles into four groups, and treats separately, one after the other, quadriceps femoris, the adductors, the inner flexors (semimembranosus and semitendinosus), and biceps by compressing them in the ordinary way, giving pétrissage, hacking, and compressing again. The best way to place the patient and oneself for comfort and ease in reaching the part is too obvious to mention. After the special treatment of the thigh one again gives effleurage over the whole limb.

After finishing the treatment of the leg one next performs abdominal massage, or the so-called abdominal kneading, as above described (Figs. 25-28). It is a very important and effective part of general massage, and should not be omitted without special reason. It should occupy about fifteen minutes.

After abdominal kneading the patient should lie on the face for treatment of the back. Although the anatomical conditions are not particularly favourable for effleurage, to help the circulation we begin and end the treatment of the back with long, quick strokings, carrying both hands one on each side of the spine up and down over the whole surface between the neck and the hips. We knead the muscles over both sides of the whole back by performing small circular movements (Fig. 13) in which the patient’s skin accompanies the hand of the masseur. One uses either the palmar surface of the whole hand, or its uppermost part (“heal” or base of hand). We then give a series of vibration-like manipulations with both hands at once, one on each side of and close to the spine, using the tips of the three middle fingers from the neck down to the lumbar region inclusive (Fig. 22), a treatment which has a very stimulating effect, but which, to be given will, needs some practice. Tapôtement is then given in the form of back hacking from the upper part of the chest to the lower part of the lumbar region, the masseur’s elbows being slightly supinated and the metacarpo-phalangeal joints slightly flexed (Fig. 20). Not only the ulnar border of the little finger comes in contact with the skin, but also its dorsal surface and that of the ring finger. Both these fingers, and especially the little finger, are held somewhat abducted; many masseurs, zealous of technique, attach great importance to a certain “feathering” done with the abducted fingers, thinking that the power to do this and back hacking altogether offers a very good criterion for a clever masseur. Each side of the back is hacked separately, and then the spine itself in many cases.

Before and after back hacking one treats the muscles of the shoulder blade by themselves by giving effleurage, tapôtement (with the finger tips), and again effleurage above and below the spine of the scapular.

The gluteal regions are next treated in the same way; but many patients dispense with this altogether. The treatment of the back ends as it began, with effleurage.

With women patients we leave the chest untouched; with men one can treat the pectoral muscles and subclavius by stroking, hacking, and repeated stroking.

If special indications exist for massage of front of neck, one may suitably end general massage with this.

In general massage all the manipulations are as a rule performed with moderate strength. It is important for patients, especially those who are having a long course of it, that it should be performed comfortably, or at least without discomfort.

If the masseur has quite dry hands, he generally uses no lubricant for general massage; if not, he uses either a lubricant or talk power for effleurage.

General massage should take at least half an hour (preferably about an hour), demands little more than mere mechanical skill, and can in most cases be quite well performed by non-medical workers. The doctor in busy practice has seldom time to give it himself, and can entrust it to any trustworthy person of the same sex as the patient, after he has once given instructions for the special case.

FOOTNOTES
(1)* The French word massage may be derived either from the Arabic mass (to press), or from the Greek anatripsis (to rub).
(2)* Vibrations are, by some authors, considered as a special fifth group of manipulations. They are distinguished however from other forms of tapôtement merely by the greater frequency of the blows in a given time and by the smallness of the movement. They aim at a similar stimulation and produce similar effects. Then vibrations are given by instrumental means on mucous membranes which are difficult to get at by means of the fingers (see later) they are really a substitute for frictions.
(3)* Busy masseurs are under constant temptation to make their séances shorter and less vigorous than is really consistent with the patient’s interest, the result of simple calculation which we leave to the perspicacity of the reader, the consequence being that their work yields quick returns only in an economic sense.
(4)* Even this bench is not at all necessary, and of later years I have myself used an ordinary couch. Plinths of different kinds are used in my Institute. During all the many years which I have used massage in my practice I have used no instrument but my hands and a vibrator. This last should be in the possession of every one who makes much use of massage.
(5)* Massage of front of neck has been used in Sweden at least since the time of Ling, who mentioned it and understood its chief effects. In our days Gerst, Weiss, and others have laid stress on its therapeutic value in various inflammatory processes and hyperæmic conditions of the head (see later).
(6)* General massage has been used in the interests of health from time immemorial (especially with baths) by nearly all Oriental, as well as by several European races, and it is widely met with as a popular remedy, for example, in the islands of the Pacific. Medically it is perhaps most often used and with much benefit as a substitute for physical exercise when this is for some reason impossible. It plays an important part in the so-called Weir-Mitchell treatment. In dystrophies, “general weakness,” and chlorosis it is also of value.

From Volume 1, Issues 1 and 2 of Massage Heritage Times. Compiled and Edited by Robert Calvert.



From Volume 1, Issues 1 and 2 of Massage Heritage Times. Compiled and Edited by Robert Calvert.

Taken from the Massage Heritage Times – archive.org

The whole material outfit* [See Footnote at bottom of column] needed by a masseur (besides the above mentioned lubricant) consists of a couch of suitable length and breadth, and about 60 cm. high, accessible from all sides, a so-called plinth, preferable with one end which can be raised or lowered according to need. When massage is given to any part of the back, buttocks, chest, abdomen, pelvis or legs, sometimes even to the shoulder joint, the patient lies on the plinth and the masseur stands or sits beside it. When massage is given to the lower part of the arm up to and including the elbow joint, the patient and the masseur sit directly opposite each other, one on either side of the plinth (upon which the patent rests his forearm). For massage of front or back of neck the patient sits on the plinth, and the masseur strands in front in the first case, behind or beside in the second. The suitable position for the patient is in most cases obvious. Where this is not the case we shall return to the subject in the special chapters.

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