The Art Of Massage (John Harvey Kellogg).pdf

 THE ART OF MASSAGE A Practical Manual for the Nurse, the Student and the Practitioner By JOHN HARVEY KELLOGG, M. D., LL. D., F. A. C. S. Author of “Rational Hydrotherapy,”...

 THE ART OF MASSAGE A Practical Manual for the Nurse, the Student and the Practitioner By JOHN HARVEY KELLOGG, M. D., LL. D., F. A. C. S. Author of “Rational Hydrotherapy,” “Light Therapeutics,” etc. Fellow of the American College of Surgeons, The Royal Society of Medicine And the American Medical Association, Member of the Societe D’Hygiene Of France, of the American Economic Association, and of the American and British Associations for the Advancement of Science, and Superintendent of the Battle Creek Sanitarium Twenty-sixth Thousand (Revised) MODERN MEDICINE PUBLISHING CO. BATTLE CREEK, MICHIGAN 1923 TEACH Services, Inc. www.TEACHServices.com  PRINTED IN THE UNITED STATES OF AMERICA World rights reserved. This book or any portion thereof may not be copied or reproduced in any form or manner whatever, except as provided by law, without the written permission of the publisher, except by a reviewer who may quote brief passages in a review. The author assumes full responsibility for the accuracy of all facts and quotations as cited in this book. ______________________________ Copyrighted, 1895, 1909, 1919, 1923 By JOHN HARVEY KELLOGG, M. D. ALL RIGHTS RESERVED ______________________________ Copyright © 1999 TEACH Services, Inc. ISBN-13: 978-1-57258-116-6 (Paperback) ISBN-13: 978-1-57258-999-5 (Ebook) Library of Congress Control Number: 96-60567 Published by TEACH Services, Inc. www.TEACHServices.com Table of Contents Cover Title Copyright Preface The Art of Massage: Its History Structures Especially Concerned in Massage Parts To Be Especially Studied by the Maseur The Physiological Effects Of Massage The Therapeutic Applications Of Massage The Procedures Of Massage Joint Movements Massage Of Special Regions Special Methods Of Zabludowski And Metzger The “Rest-Cure" Rules Relating To Massage Correct Use Of Terms The General Physiology, Names, Nerve Supply, And Actions Of The Muscles Of The Human Body X-Ray and Massage Massage In The Treatment of Fractures The Mobilization of Joints Special Movements and Breathing Exercises The Schott Method Recent Progress In Massage TEACH Services, Inc  Preface WHEN the writer began the therapeutic employment of massage, this method was generally looked upon with more or less suspicion as being closely allied to quackery if not absolutely irregular. In those days there were many magnetic healers who cured by laying on of hands, and in New England there was a family of bone-setters who had developed a considerable local reputation by the peculiar manipulations which they practiced upon their patients, not infrequently to their decided detriment. Fifty years ago there were in this country few if any persons who were really skilled in massage. It was only by visiting Stockholm, Sweden, and Germany and France that it was found possible to obtain a practical knowledge of the subject. After the employment of massage by the aid of a score or more of well trained manipulators during the last fifty years, the writer’s faith in the efficacy of this measure as a means of reaching definite therapeutic results is far greater than at the beginning. As the years have passed, abundant opportunities have offered, for testing the various systems and methods which have been presented in this country and Europe, and the result has been the development of very clearly defined methods. The author’s constant purpose has been to eliminate the unnecessary and inefficient, and to develop and perfect those methods capable of securing most definite and prompt results. Special attention has been given to massage of the abdominal region and the important accessory means of influencing the vital organs which are found in this region of the body. The physiologic research which has been applied to the methods of massage within recent years has clearly demonstrated the effectiveness of external manipulations as a means of influencing metabolic and other processes in the deeper parts of the organism. At the present time it may be said to be clearly established that every organ and every function of the body may be influenced by the procedures of massage. Both the volume of blood and the movement of blood in every internal viscus may be decidedly influenced in either direction by external manipulations. Specific effects of the various external applications are pointed out in the physiologic portion of this work. In this book the writer has sought to describe as clearly as possible the various procedures of massage as practiced at the Battle Creek Sanitarium, where there has been perhaps a larger and more continuous experience with this method than at any other center in the United States. Since the publication of the first edition (1895), a system of manipulations designated by the term “Osteopathy” has become widely known throughout the country. At the beginning this method was greatly lacking in the necessary characteristics of a scientific system, and its recognition by the medical profession has been greatly hindered by the extravagant claims and unscientific methods of its early promoters. It has been interesting, however, to note the considerable progress which has been made by the practitioners of this system toward a more scientific method by the elimination of fallacious and pretentious claims and the more thorough training of its practitioners in the fundamental facts and principles of medical science. At the present time there are almost as many different kinds of Osteopaths as there are different sects in Christendom. There are many different osteopathic schools and each one has its own system. All differ very considerably among themselves, but if we may credit assurances received from a leading teacher in one of the leading osteopathic colleges of the country, there is an increasing movement away from the original empirical Osteopathy, and toward scientific medicine as understood by the more progressive of modern medical leaders. It is prophesied by this class of Osteopaths, and the prophecy may be easily believed, that the time is not very far distant when the term “Osteopathy” will disappear except as an interesting relic of pseudoscientific medicine, and so-called Osteopathy, purged of its unscientific ineumbrances, will be swallowed up by scientific medicine. There are already marked signs of such an assimilation.  From the writer’s standpoint, there is little to be found in original Osteopathy which is not included in scientific massage and manual Swedish movements when thoroughly understood and efficiently applied. Credit must be given Osteopathy, however, for having emphasized this class of therapeutic measures and compelled its recognition and its advancement to a much more permanent place in therapeutics than it previously enjoyed. That it was necessary to wait for this to be accomplished by a pseudo-scientific cult like Osteopathy is no particular credit to the medical profession. The only proper attitude for the profession at the present time is to accept and utilize every principle presented which is supported by anatomic and physiologic facts, and thus encourage those who recognize the therapeutic value of manual manipulations to fit themselves by broader medical study to join the ranks of scientific medicine. The history of medicine shows that it has constantly been enriched by therapeutic contributions from sources outside the recognized medical authorities. Hydrotherapy found its development among the peasantry of Austrian Silesia ; massage came from the most primitive sources, being borrowed originally from the ignorant savages of the South Sea Islands. Electricity was for a century a magic wand in the hands of charlatans. Hypnotism, now recognized by some as a scientific method, originated with the charlatan, Mesmer. Science will recognize truth, no matter what its origin may be. In the teaching of therapeutics, too exclusive attention has been given to the study of drugs and drug medication. Dietetics, electrotherapy, hydrotherapy and particularly massotherapy and kinesotherapy have been so greatly neglected that it is not strange that men impressed with the value of these procedures should have undertaken to create of them a specialty and a new sect in medicine. But physiologic medicine is making marvelous progress in recent years. A more liberal and progressive spirit is growing in the medical profession, and the time is not far distant when all medical sects will disappear, and scientific medicine will stand forth as the representative of all curative methods which possess real merit. Indeed, this is the real position of scientific medicine. The author desires to call the attention of those who specialize in massotherapy to the importance of utilizing other forms of physiotherapy in connection with massage. Hydrotherapy is especially useful as a supplement or complement of massotherapy. Every physiologic method has its special advantages and certain characteristic disadvantages. Massage is especially valuable as a means of quickening the circulation and other forms of vital activity. This is its characteristic effect. When skilfully applied, it may sometimes serve as a means of relieving pain, but this is one of its lesser, and one may say, its natural and inconstant effects. Not infrequently pain is temporarily increased by massage, either in consequence of an increased volume of blood or because of lack of perfect adaptation of technique to the individual ease. In either instance the masseur may not be at all blameworthy, for it is not possible, especially when first taking a case in charge, to adapt treatment with a nicety to the unknown conditions present. Hydrotherapy offers, in both classes of cases referred to, assistance of the greatest value as a means of combating inflammatory conditions, and especially as a means of relieving pain. It is often highly advantageous to apply hot fomentations or other heating measures in connection with massage, especially in the treatment of painful joints. The heating compress is another hydriatic measure of great value in cases. The photophore, the arc light, and the thermophore are other measures which promote and supplement the beneficial effects of massage. Dietotherapy must also receive due share of attention. This is especially true in the management of cases of rheumatism, gout, constipation and obesity. Change of the intestinal flora by the means now well known to be efficient, and adherence to a strictly antitoxic or non-toxic diet will remove the deep lying causes of distressing symptoms which in many cases massage can offer nothing more than palliation. In presenting this new edition of a handbook, more than twenty-five thousand copies of which are already in the hands of the physicians and nurses of this and other English-speaking countries, the author desires to express his appreciation of the recognition which has been given his efforts to promote the good cause of physiologic medicine which has in recent years advanced so rapidly in prestige and popularity. Battle Creek, Mich., J. H. K. Nov. 19, 1922.  The Art of Massage: Its History MASSAGE, or systematic rubbing and manipulation of the tissues of the body, is probably one of the oldest of all means used for the relief of bodily infirmities. There is evidence that massage was employed by the Chinese as early as 3000 years ago. Their literature contains treatises upon the subject written some thousands of years ago. An ancient Chinese book entitled, “The Cong-Fou of the Tao-Tse,” of which a French translation appeared about a century ago, was probably the foundation both of our modern massage and of the manual Swedish movements so admirably elaborated and systematized by Ling. Massage is still very extensively employed by the Chinese, and also by the Japanese, who doubtless learned the art from the Chinese. Among the Japanese, massage is employed almost exclusively by blind men, who go about the streets soliciting patronage by shouting in a loud voice the words Amma! amma! (shampooing, or massage). Fig. 1 represents one of these blind masseurs crying his vocation upon the streets of Mito, Japan. Fig. 2 shows one of them administering massage to a lady patient. These engravings are photo-reproductions from photographs kindly sent to the writer by a friend in Japan. The same friend also sent the following description of his personal experience with Japanese massage, which was administered to him by a first-class manipulator, for the relief of a severe cold accompanied with fever: - “The shampooer sat in Japanese fashion at the side of the patient, as the latter lay on a futon (thick comforter or quilt) on the floor, and began operations on the arm; then took the back and the back of the neck, afterward the bead (top and forehead), and ended with the legs. On the arms, back, back of the neck, and legs, he used sometimes the tips of his fingers, sometimes the palms or the backs of his hands, sometimes his knuckles, sometimes his fists. The movements consisted of pinching, slapping, stroking, rubbing, knuckling, kneading, thumping, drawing in the hand, and snapping the knuckles. The rubbing in the vicinity of the ribs was slightly ticklish, and the knuckling on the back of the neck, and at the side of the collarbone, a little painful. On the head he used gentle tapping, a little pounding with his knuckles, stroking with both hands, holding the head tight for a moment, grasping it with one hand and stroking with the other. The operator seemed to have a good practical knowledge of physiology and anatomy, and certainly succeeded in driving away the headache and languor, in producing a pleasant tingling throughout the body, and in restoring the normal circulation of the blood. He is to be criticised, however, for one serious fault in his operations,—that of shampooing down, instead of up. A portion of the good done is thus neutralized, one object of scientific massage being to help back toward the center the blood which is lingering in the superficial veins.” I do not agree with my friend’s criticism of the mode of manipulation employed by the Japanese masseur, who seems to have been more skilled than most of our own manipulators, since be was apparently aware of the fact that the limbs should be rubbed down, rather than up, for the relief of the condition of feverishness and irritation from which his patient was suffering. Massage has been employed from the most ancient times by the Hindoos and Persians, who still practice it, some of their native masseurs being possessed of remarkable skill. The ancient Greeks and Romans also employed massage constantly in connection with their famous baths. Hippocrates, the renowned Greek physician, made extensive use of this mode of treatment, designating it anatripsis. He evidently appreciated the principles of the art very well, as he directed that friction should be applied centripetally, or in the direction of the veins. That he understood the effects of different modes of application is shown by the following quotation from his works: “Friction can relax, brace, incarnate (fleshen), attenuate; hard, braces ; soft, relaxes; much, attenuates; and moderate, thickens.” Hippocrates learned massage, as well as gymnastics, from his teacher Herodicus, the founder of medical gymnastics. Asclepiades, another eminent Greek physician, held the practice of this art in such esteem that he abandoned the use of medicines of all sorts, relying exclusively upon massage, which he claimed effects a cure by restoring to the nutritive fluids their natural, free movement. It was this physician who made the discovery that sleep might be induced by gentle stroking. Plutarch tells us that Julius Caesar, a century before the Christian era, had himself pinched all over daily for neuralgia. It is well known that Julius Caesar was subject to a severe nervous disorder (epilepsy), and it is more than probable that his prodigious labors were only rendered possible by the aid derived from massage. Pliny, the great Roman naturalist, had himself rubbed for the relief of chronic asthma. Arrian recommended massage for horses and dogs, asserting that it would strengthen the limbs, render the hair soft and glossy, and cleanse the skin. After giving directions for massage of the legs, abdomen, and back, he directed that the treatment should be terminated in the following peculiar manner, which indicates that he understood the value of nerve-stretcbing, at least for dogs: “Lift her up by the tail, and give her a good stretching ; let her go, and she will shake herself and show that she liked the treatment.” Celsus, the most eminent of all Roman physicians, who lived at the beginning of the present era, was very familiar with massage, and used great discretion in its application. He recommended manipulations of the head for the relief of headache, and general manipulations to restore the surface circulation in fever, making this wise remark: “A patient is in a bad state when the exterior of the body is cold, the interior hot with thirst; but, indeed, also, the only safeguard lies in rubbing.” Galen, the greatest physician of his time, in the second century recommended massage in many diseases. He seems to have had a good understanding of the various forms of friction and kneading. A sort of percussion, called whipping, was employed by the ancient Roman physicians in various diseases, and is still used by the Laplanders and the Finns, who beat the body with bundles of birch twigs. The natives of the Sandwich Islands have, from the most ancient times, employed massage, which they term lomi-lomi. They frequently administer lomi-lomi to an exhausted swimmer while in the water, supporting him with their hands until his forces are rallied by the manipulations. The Maoris of New Zealand practice massage under the name of romi-romi. The accompanying cut (Fig. 3) shows a Polynesian, a son of a chief, administering the treatment. The natives of Tonga Island employ massage under the name of toogi-toogi, the literal meaning of which is “to beat,” for the relief of sleeplessness, fatigue, etc. Melee denotes rubbing with the palm, and fota kneading with the thumb and fingers. Paracelsus, the prince of charlatans, who flourished at Basle, Switzerland, four hundred years ago, made great use of massage, and taught it to his pupils in the medical school of that city. Massage has been used in France for two hundred years. It was much employed in the early part of the present century by eminent English surgeons, especially in the treatment of sprains and other injuries of the joints. Its use in modern times, however, is chiefly due to its systematic development and employment by Mezger, of Amsterdam. Genuine Works of Hippocrates, Vol. 11, page 16.  Structures Especially Concerned in Massage Massage, in its varied applications, has either direct or indirect relation to every structure and function of the body; but in its ordinary applications, this therapeutic measure directly and immediately affects especially the following: - 1. The skin, with its connective tissue network, its sebaceous and sweat glands, hair follicles, and the infinite number of minute blood vessels and sensitive terminal nerve filaments —trophic, vasomotor, and sensory. 2. The connective tissue lying just beneath the skin, with its rich supply of veins and lymph vessels and spaces. 3. The muscles which chiefly constitute the fleshy portions of the body, and which receive special attention in the various manipulative procedures of massage, both as individual muscles and as functional groups. The muscles constitute about one half the weight of the body. They receive about one fourth of the blood. When their vessels are dilated under the influence of exercise or massage, they may contain one half of the blood. The body heat is chiefly generated in the muscles by the oxidation, or burning up, of the glycogen deposited in them from the blood. When the muscles are active, one fourth of the energy set free is expended in work, three fourths in heat. Voluntary muscular exercise expends the energy of both the nerve centers and the muscles. Massage stimulates vital activity in the muscles without taxing the nerve centers. The muscles are constantly active under the influence of the nervous system, even when in a state of apparent rest. This insensible activity is known as muscle tone. It is very noticeable in the abdominal muscles, the tone of which enables the muscles to act in opposition to the diaphragm, aiding in expiration. Massage increases muscular tone by improving their nutrition. 1. The large blood vessels, both veins and arteries, but principally the veins, the circulation of which may be readily accelerated or impeded according as the manipulations are applied in the direction in which the, blood runs in the veins, or in the opposite direction. The large lymph channels which usually accompany the larger veins are also brought directly under the influence of massage through appropriate manipulations. The heart itself may be reached by certain special-procedures, and is greatly influenced by nearly all forms of manipulation. 2. The large nerve trunks, which, with the terminal nerve filaments, are influenced by all forms of manipulation, but especially so by certain procedures which are particularly efficacious in producing stimulating or sedative effects. 3. All the large viscera of the abdomen,—stomach, colon, small intestines, pancreas, spleen, liver, kidneys,—which may be brought more or less directly under the influence of massage by a skilled operator; while less directly, but still effectively, the lungs and heart may also be influenced by certain procedures. 4. The bones, joints, and ligaments must also be mentioned as structures which are directly affected by massage. The student of massage should make a careful study of the muscles, bones, and joints, and, in fact, so far as possible, of the entire anatomy. To facilitate this study, a number of colored plates have been prepared, which are exact reproductions of the famous copper-plate engravings prepared under the direction of the eminent German anatomist, Bock.  Parts To Be Especially Studied by the Maseur A proper understanding of massage and its skillful application requires a good knowledge of anatomy. Physiology is also of the highest value to the masseur, but a practical study of anatomy is absolutely indispensable. This is not the place for a detailed anatomical consideration of the body, but the learner may perhaps be somewhat assisted by the following brief enumeration of some of the anatomical structures with which he must become familiar:— The Bones.—First of all, the student of massage should make a serious study of the bones (Fig. 4), as in all the manipulations of massage their conformation must be kept carefully in mind. Every bony prominence, hollow, furrow, ridge, articulating surface, together with the points of origin and insertion of the principal muscles; in relation to the skull, the points of entrance and exit of nerve trunks, arteries, and veins; also the joints and ligaments (Figs. 5-llb), should be made thoroughly familiar by a minute and careful study of the skeleton. The following points in relation to the skeleton should receive special attention:— 1. Head : Vertex, occiput, parietal eminence, mastoid process, zygoma, temporal fossa, orbit, angle of lower jaw. 2. Neck : Cervical Vertebræ, vertebra prominens, hyoid bone. 3. Chest : Dorsal vertebræ; twenty-four ribs (on each side, seven true ribs, three false ribs, two floating ribs); sternum, cartilages of ribs, xiphoid cartilage. 4. Arm : Shoulder bones, consisting of the scapula, or shoulder blade, with its spine, acromion process, coracoid process, and glenoid cavity ; clavicle, or collar-bone; humerus or upper arm bone; head, neck, tuberosity, internal and external  condyles. 5. Forearm: Ulna, olecranon process, sigmoid cavity, styloid process; radius, head. 6. Hand : Eight carpal bones, five metacarpal bones, fourteen phalanges. 7. Spine : Eight cervical, twelve dorsal, and five lumbar vertebræ; sacrum, coccyx. 8. Pelvis : Sacrum, coccyx, ilium, crest of ilium. pubes, tuberosity of ischium, acetabulum. 9. Thigh : Femur, or thigh bone-head, neck, great trochanter, lesser trochanter, outer and inner condyles, popliteal space. 10. Lower Leg : Patella; tibia—head, outer and inner tuberosities, tubercle, internal malleolus, crest; fibula—styloid process, external malleolus. 11. Foot : Tarsus, seven bones—os calcis, astragalus, cuboid, scaphoid, three cuneiform; metatarsal bones, five; phalanges, fourteen. The Muscles.—The following is a list of the principal muscles (Fig. 12) which are dealt with in the different regions to which massage is especially applied:— 1. Cranium : Occipito-frontalis. 2. Face : Muscles of mastication, forming the fleshy portion of the cheek, and situated at the back part of the face; muscles of expression, found chiefly about the eyes, nose, and mouth (Fig. 13). 3. Neck : Posterior, trapezius; anterior, muscles which act upon the hyoid bone; lateral—sterno-mastoid, platysma rnyoides, scaleni (Fig. 14). 4. Upper Back : Trapezius, supra- and infra-spinatus, rhomboid (Fig 16). 5. Lower Back : Extensors and latissimus dorsi (Fig. 16). 6. Chest : Pectoralis, major and minor, serratus magnus (Fig. 15). 1. Abdomen: Rectus, external oblique, quadratus lumborum (Fig 15). 2. Shoulder : Deltoid and supra-spinatus, which raise the arm;  infra-spinatus and teres minor, which rotate arm outward and bold shoulders back; teres major and latissimus dorsi, which rotate arm inward and draw arm to side (Fig 16). 3. Arm : Anterior, flexors—biceps, coraco-brachialis, and brachialis; posterior, extensor—triceps (Fig. 15). 4. Forearm : Radial (thumb) side, supinators, extensors, and thumb flexor; ulnar (little finger) side, flexors, pronator teres (Fig. l5). 5. Hand : Palmar surface—short flexors of fingers; dorsal surface—interossei. 6. Hip: Glutei, which rotate thigh outward and inward and abduct it; obturators and pyrifornis, which tilt pelvis forward, increasing obliquity of the pelvis (important in relation to correct standing). With thighs flexed upon abdomen, nearly all the muscles of the hip except the obturator, externus (which rotates femur outward) act as abductors (Figs. 18, 19). 7. Thigh : Anterior, extensors, quadriceps (Fig. 17); posterior, flexors (Fig. 19); internal, adductors (Fig. 20). 8. Lower Leg: Inner portion—extensors of foot and flexors of toes, gastrocuemius (Fig. 20); anterior, flexors of foot and extensors of leg, tibialis anticus (Fig. 17) ; outer and upper —extensors, peronei (Fig. 18). 9. Foot: Plantar surface, flexors of toes; dorsal, interossei. Veins.—The arteries are not so important in massage as are the veins, as they lie too deep to be influenced to any considerable degree by the manipulations ordinarily employed. 1. Neck: Jugular (Fig. 21). 2. Arm: Axillary and brachial (upper); cephalic (outer); basilic (inner) (Fig. 21). 3. Forearm: Radial (outer); anterior ulnar (inner); median anterior, posterior ulnar (posterior) (Fig. 21). 4. Leg: Femoral (upper anterior); long saphenous (inner anterior, beginning at arch of foot); short saphenous (posterior outer, beginning behind the outer malleolus); popliteal (Figs. 22, 25). The Nerves.—So large a proportion of the physiological effects obtained by the employment of massage being the result of reflex action, it is highly important that the masseur or the student of massage should have a good knowledge of the physiology of the nervous system. The more he knows of anatomy the better, but he must know the names and location of the principal nerve trunks. The location of those which will be mentioned is so clearly shown upon the colored plates that it will not be necessary to do more than name them here. 1. Face : Facial, trifacial (Fig. 27). 2. Arm : Median, ulnar, musculo-spiral (Figs. 23 and 24). 3. Leg : Crural, sciatic (Fig. 25). The sacral nerve passes across the sacro-iliac synchondrosis, or junction of the sacrum and ilium. The pneumogastric, or par vagum, is the large nerve from the brain, which passes down the side of the neck, entering the chest just behind the top of the sternum, near the median line. It is distributed to the heart, lungs, and all the abdominal viscera (Fig. 27). The sympathetic nerve controls the function of the digestive organs, kidneys, liver, and other viscera of the abdomen, all the glands of the body, and the action of the heart and blood vessels. Its principal divisions of interest to the masseur are the cervical ganglia, the renal plexus, the hepatic plexus, the lumbar or umbilical ganglia (situated at the back of the abdominal cavity and two inches on either side of the umbilicus), and the subumbilical ganglion, or lumbar aortic plexus, located two inches below the umbilicus (Fig. 27). The Viscera.—Nearly all the contents of the abdomen and pelvis may be brought under the direct influence of massage. Their general form and normal location should be carefully studied (Figs. 28, 29, 30, 31); viz., the heart, stomach, pancreas, liver and gall bladder, spleen, kidneys (right lower than left), colon, appendix vermiformis, bladder, prostate gland, uterus, Fallopian tubes, and ovaries. Landmarks and Regions.—While the profound knowledge of surgical landmarks and regions important for the physician is not needed by the masseur, some knowledge of this kind is essential to skillful work. The student is advised to familiarize himself with the following, by the aid of a good anatomy:— Linea alba, the median line of the body, extending from the sternum to the pubes. Linea semilunaris, the outer border of the rectus muscle. Umbilicus, commonly called the navel, located, in symmetrical persons, midway between the end of the sternum and the pubes, normally higher in women than in men. Poupart’s ligament, the fibrous band connecting the anterior superior spine of the ilium with the spine of the pubes. External inguinal ring, an opening in the abdominal wall just above the spine of the pubes, through which the spermatic cord passes in the male and the round ligament in the female; larger in men than in women.  Femoral ring, an opening below Poupart’s ligament, the seat of femoral hernia; larger in women than in men. Axilla, the armpit, space under the arm bounded by tendons, in front by the pectoral muscles, and behind by the sub-scapular, teres major, and latissimus dorsi muscle. Enlarged glands are often found in the axilla. Groin, the fold at the junction of the leg with the body, a little below Poupart’s ligament. A number of enlarged glands are often felt in this region, even in healthy persons. Popliteal space, the space underneath the knee. It contains large vessels and nerves, hence too strong pressure in this region should be avoided. Fold of the buttocks, the furrow just below the buttock, marking the lower border of the large gluteal muscle. The regions of the abdomen may be said to be nine in number, divided by lines drawn upon the surface (Fig. 30),—right hypochondriac, left hypochondriac, epigastric, right lumbar, left lumbar, umbilical, right inguinal, left inguinal, hydrogastric.  The Physiological Effects Of Massage The interest in the therapeutic applications of massage which has increased so rapidly within the last twenty years has led to numerous investigations by able physiologists for the purpose of determining with exactness the physiological effects of the various procedures included under the general term massage, and thus obtaining a correct basis for their therapeutic use. Many of these experiments have been repeated and verified by the writer in the physiological laboratory under his charge in connection with the Battle Creek Sanitarium, and some of the results will be recorded in an Appendix, in addition to this brief summary of the conclusions which have thus far been obtained by those who have most carefully studied the subject. These investigations have established beyond all possibility of question, that massage affords one of the most effective means of influencing the functions of the human body. Experiments clearly show that every function of both animal and organic life may be powerfully influenced by some or all of the numerous procedures of massage. The various effects produced may be included under the following heads : — 1. Mechanical, in which the tissues are wholly passive, being simply acted upon in a mechanical way by the hand of the manipulator, as in the movement of the blood and lymph in the venous and lymph channels, or the restoration of a displaced viscera to its normal position. 2. Reflex, in which the peripheral and central portions of the nervous system, both cerebro-spinal and sympathetic are chiefly active, an impression made upon the nerve ends of the sensory or afferent fibers connected with the nerve centers of the cerebro-spinal and sympathetic systems being transmitted to the related centers, where new activities are set up, resulting in the sending out of nerve impulses by which vital changes are effected, not only in the parts directly acted upon, but in related parts. 1. Metabolic, in which important modifications occur in the tissue activities both of the parts directly operated upon and of the body as a whole, as the result in part of the direct mechanical effects of massage upon the tissues, and in part  of the reflex activities set up by it. In a brief manual like this there is not space to consider in detail the modus operandi of all the different effects of massage. We must be content with a simple enumeration of the specific effects upon the principal systems and functions of the body. Effects of Massage upon the Nervous System.— All the different procedures of massage produce a decided effect upon the nervous system through the influence of the manipulations upon the nerve endings of both the cerebro-spinal and the sympathetic -nerves, which are found in so great abundance in the skin and muscles-the former in connection with the special senses of locality, temperature, pressure, and weight; the latter more especially in connection with the glands, blood vessels, and thermic mechanism located in the skin and muscles. 1. Direct Stimulating Effects.—Vibration and nerve compression may be made to act directly upon nerve trunks, thereby causing powerful stimulation not only of the peripheral nerves but of all the nerve centers with which a nerve trunk is connected. Friction is an effective means of exciting languid nerves. Light percussion simply increases nervous irritability, while strong percussion may cause so great a degree of nervous irritability as to exhaust the nerves, and thus produce a benumbing effect. Tapping, slapping, clapping, and hacking are the most effective means of exciting nerve trunks. Beating and vigorous hacking are especially useful for exciting the nerve centers, and hence are especially applicable to the spine. The nerve centers may also be directly excited by deep vibration and by strong percussion.  1. Reflex Effects —The reflex effects of massage are very remarkable and exceedingly interesting. All the procedures of massage produce powerful reflex effects. Some of the most striking effects are produced by very light stroking, especially when applied to certain reflex areas. (See Reflex Stroking.) Percussion and vibration are also powerful means of producing reflex effects, which include not simply muscular action, but increase or decrease of vascular and glandular activity, and general tissue change. 1. Sedative Effects.—The sedative effects of massage are equally as marked as the stimulating effects. Strong percussion relieves pain in the same manner as does strong faradization, by tiring out and thus obtunding nerve sensibility. Pinching produces an anesthetic effect in essentially the same way. The physician always pinches the skin before introducing the hypodermic needle. Sedative effects are also produced by gentle stroking—the so-called hypnotic effect, doubtless, through reflex influence upon the nerve centers. Very marked sedative effects are produced by derivative friction and kneading. Centrifugal friction (rubbing down) diminishes the blood supply of the brain, and hence lessens cerebral activity. Light friction over a deep-lying organ diminishes its blood supply by increasing the activity of the overlying vessels, thus causing the blood to go around instead of through it. Massage of the soft parts above a joint, and movements of the next joint above, relieve pain by emptying the lymph and blood vessels of the part. 1. Restorative or Reconstructive Effects.—Mental fatigue is relieved by massage, through its effect upon the circulation and the eliminative organs. The toxic substances produced  by mental activity, are more rapidly oxidized and removed from the body, while the hastened blood current more thoroughly repairs and cleanses the wearied nerve tissues. General reconstructive effects are experienced by the entire nervous system through the improved nutrition induced by massage. Effects of Massage upon the Muscular System.— Massage, when skillfully administered, has to do chiefly with the muscles. That form of manipulation which consists simply of skin-pinching excites the nervous system and the surface circulation, but has little influence upon the muscles. When we reflect that the muscles constitute one half of the bulk of the body, and receive one fourth of all the blood of the body, it is at once apparent that any procedure which acts directly upon them must have a decided influence upon the whole body. Although the muscles constantly receive a certain blood supply, this supply is comparatively small except during activity; consequently, it may be said that “the muscles are well fed only when exercising.” When the muscle is inactive, the blood goes around it rather than through it ; but the moment activity of the muscle begins, there is a great increase in its blood supply, even before any acceleration in heart activity has occurred. Massage may serve to a considerable extent as a substitute for exercise by increasing the blood supply of a muscle, just as exercise may be considered a sort of massage, through the pressing and rubbing of the muscles against each other. When properly administered, the manipulations of massage act upon the muscles in such a way as to produce a suction, or pumping effect, pressing onward the contents of the veins and lymph channels, and thus creating a vacuum to be filled by a fresh supply of fluid derived from the capillaries and the tissues. Specific Effects of Massage upon the Muscles.—Massage in its specific effects upon the muscles, may be said to accomplish the following results :—  1. To Encourage Nutrition and Development of the Muscles. The increased blood supply of the muscle induced by massage naturally improves its nutrition. Experience shows that, when systematically and regularly employed, massage produces an actual increase in the size of the muscular structures. The muscle is also found to become firmer and more elastic under its influence. Massage feeds a muscle without exhausting it, in which respect it differs from exercise ; nevertheless, it is not a complete substitute for exercise, for the reason that exercise brings into active play the whole motor mechanism—nerve center, nerve, and muscle—while massage affects chiefly the muscle. The improvement in the nutrition of the muscle, as regards increase in size or firmness, is seldom noticeable for the first three or four weeks, and the most marked effects should not be expected until after two or three months. 1. To Excite Muscular Contraction.—A smart blow upon a muscle is one of the ways by which contraction may be excited. By a succession of blows, one following another with sufficient rapidity, tetanic contraction of a muscle may be induced. Strong vibration will also cause tetanic contraction of a muscle ; but very rapid and strong vibrations are required to produce tetanus. In voluntary tetanus (ordinary muscular contraction) the number of impulses received by the muscle per second is ten to twenty. It is evident that the rate of vibration required for producing tetanus must be as great or greater and consequently mechanical means of some sort must be applied, as the highest rate of movement which can be communicated by the hand directly is ten to twelve double movements per second. A vibratory apparatus which I have had in use for many years, and which produces decided muscular contractions, has a movement of sixty per second.  In certain cases, muscular contraction may be induced more readily by the application of percussion than by the faradic current. 1. To Increase Electro-excitability of the Muscle.—Numerous  experiments have shown that massage increases the electro- excitability of a muscle, as indicated by the fact that a smaller number of milliamperes of current is required to cause contraction of the muscle after massage than before. According to Kroneker, however, a muscle is less easily tetanized after massage than before, but its power of action is greatly increased. An abnormal degree of muscular irritability is certainly relieved by massage. This effect of massage may be advantageously utilized as a preparation for applications of electricity in cases in which the electro-excitability of a muscle is diminished by trophic changes, as in infantile paralysis. 1. To Remove the Effects of Muscular Fatigue.—Ranke, Helmholtz, Du Bois-Raymond, Mosso, and more recently, Abelous, have conclusively shown that special toxic substances are produced as the result of muscle work, and that the phenomena of fatigue are due to the influence of these substances upon the nervous and muscular systems. Abelous has shown that the first effect is a sort of auto-curarization, or paralysis, of the terminal motor plates of the nerves which actuate the muscles, while in advanced fatigue the muscle itself is exhausted by the consumption of the material (glycogen) necessary for work. The fact that a fatigued muscle can be restored to full vigor at once by simply rinsing its vessels with a normal saline solution, as shown by Ranke, demonstrates the toxic character of the phenomena of fatigue. Bowditch, Bernstein, and others have shown that the nerve itself is indefatigable. Zabloudowski has shown that frogs completely exhausted by faradization of the muscles, although not restored by fifteen minutes’ rest, were revived at once by massage, and were even able to do twice as much work as before. In another experiment, a man lifted with his little finger, one kilo (2 1-5 lbs.) 840 times, lifting the weight once a second. The muscles of his finger were then completely exhausted. After five minutes’ massage he was able to lift the same weight 1100 times, and his muscles were even then not greatly fatigued. The Sandwich Islanders employ massage under the name of lomi-lomi as a means of resting fatigued persons, and sometimes even apply it to restore an exhausted companion when swimming long distances in company. An intelligent native Maori informed the writer that the same method is used by the natives of New Zealand to relieve cramp resulting from cold when swimming in the sea. The term used for massage among the Maoris is romi- romi, the literal meaning of which is the same as petrissage in the French. The stiffness and soreness of muscles which occur from so called consecutive or secondary fatigue resulting from over-exercise, is also relieved by massage. It should be remembered, however, that secondary fatigue may be produced by too vigorous an application of massage in a person not accustomed to it, especially in those who are very fleshy. Muscular Electricity.—Physiological experiments have demonstrated that with each muscular contraction an electrical discharge takes place, and Mervy has shown that a muscle is a sort of electrical accumulator, electricity doubtless being generated by the muscular and thermic activities which are constantly present in the muscle. As an accumulator it is auto- excitant, and may also be excited by induction or by contact. In this way the muscles of the person massed may be favorably influenced through induction from the more highly charged muscles of the masseur. This influence, however, must be very slight, and its therapeutic value can scarcely be said to be established. Effects of Massage upon the Bones, Skeleton, and Ligaments.—That massage is capable of influencing such hard structures as the bones, ligaments, and cartilages, is clearly demonstrated by numerous facts and observations. A bone has essentially the same blood supply as its overlying muscles. It is for this reason that the same exercise which causes increase in the size of a muscle, at the same time induces growth in the bone to which the muscle is attached. The bones and joints of persons who are much addicted to exercise are decidedly larger than those of persons who have made little use of their muscles. This is especially noticeable in comparing the large, strong hand and knotty knuckles of the laboring man with the puny band and straight, slender fingers of the man of sedentary pursuits. The blood vessels and lymphatics are largest in the vicinity of the joints, and the change of fluids effected by joint movements, resulting from the action of the muscles upon the bones, necessarily produces increase in the nutrition of the parts, and consequently an increased growth in the cartilages, ligaments, and other structures of the joint. It is now known that the red matter of the bones is the blood forming tissue of the body. This fact gives a new importance to massage, since the acceleration of the circulation of the blood through the muscles must improve the nutrition of the bones as well as of the muscles, thus favorably influencing the blood-making processes both as regards the quantity of the blood produced and its quality. Effects of Massage upon the Circulation.—Massage profoundly affects the circulation, both general, and local, its effects differing, however, according to the mode of application and the part acted upon. General massage increases the rate and the force of the heart beat, as does exercise, with the difference that it does not raise the arterial tension as does exercise, and does not accelerate the heart to the same degree, though producing a full, strong pulse. This is due to the fact that the influence of massage is chiefly upon the peripheral circulation. The vigor of the circulatory activity is increased not only in, answer to the greater demand for the removal of the poisons resulting from oxidation as in exercise, but through the mechanical assistance afforded by massage, in moving the blood forward, in the venous and lymph channels, and in setting up reflex activities whereby the small vessels are dilated and their activities quickened. The reflex influence of massage acts as a tonic for the heart, while the dilatation of the vessels decreases the resistance so that the heart acts more freely and efficiently in performing its functions. Recent experiments by Brunton, verified by the author, show that general massage produces at first, but briefly, a rise in arterial pressure. Locally, the effect of massage is to produce an active hyperemia of the part. Under the influence of massage the blood vessels become more active, pumping forward the blood into the veins, through which its flow is assisted materially by the manipulations. The increase of blood is usually accompanied by reddening of the surface and an increase of warmth, sensibility, and general vital activity. Light percussion of the surface causes contraction of the blood vessels of that portion of the skin acted upon. Strong percussion very quickly produces dilatation of the blood vessels which may even amount to paralysis. Light percussion, if sufficiently prolonged, also produces dilatation. When applied to a reflex area, percussion doubtless also excites the circulation in the vessels of the related nerve centers. Massage, of the abdomen slows the pulse by raising the general blood pressure. This is accomplished both by the stimulation of the abdominal muscles, thus increasing the intra-abdominal pressure, and also by the stimulation of the vaso-constrictors of the abdominal vessels. At the same time, a collateral hyperamia of the skin and the abdominal muscles is produced and thus visceral congestion is diminished.  Massage has chiefly to do with the circulation of fluid in the veins and the lymph channels, since these are more readily accessible from the surface than the arteries. Friction acts chiefly upon the superficial veins, while petrissage and other forms of deep kneading act upon the deeper vessels as well. Indirectly, the portal and pulmonary circulations are also influenced by massage. Massage of the extremities, for example, especially if concluded with centrifugal friction, may relieve congestion of both the portal and the pulmonary systems. Massage of the legs acts more directly upon the portal system, while massage of both extremities favorably influences the pulmonary circulation in case of congestion of the lungs. Massage of the arms and legs also acts derivatively upon the brain and spine. For derivative effects upon the brain, however, care should be taken to avoid such exciting procedures as percussion and reflex stroking. Massage also has a powerful effect upon the circulation by promoting the action of the diaphragm, which serves efficiently as a pump in assisting the circulation, as well as in carrying on the process of respiration. M. Camus has shown by experiments upon dogs that the increase either of the rate or the depth of respiratory movement increases the flow of lymph in the thoracic duct. The same has been shown in regard to the blood circulation by numerous investigators. The influence of massage upon the lymph circulation is especially worthy of attention. The lymph vessels drain the tissues of waste and toxic substances, and prevent clogging from wandering cells. Lymph channels are most abundant in the subcutaneous tissue and in the fascia which cover and lie between the muscles, so that these vessels are mechanically acted upon in massage, especially by friction and kneading movements. That massage and exercise of muscles greatly increase the flow of lymph has been repeatedly demonstrated by experiments upon animals, as, for example, it was found that the flow in the lymph vessels of a dog’s leg nearly ceased when the animal was quiet, but as soon as the limb was exercised or massaged, the flow of lymph began again (Reibmayr). It has also been shown that the flow of lymph from a limb in a state of inflammation was very easily induced, and was seven or eight times greater than from a sound limb. A swollen limb was found to diminish during the flow of lymph (Lassar). The same author has shown that massage of a lymph gland increases the outflow of the fluid. Deep massage applied to a limb diminishes its size. The central tendon of the diaphragm contains a large number of lymph channels. The diaphragm may be regarded as a great lymph pump, since by its rhythmical movement, the lymph channels are alternately dilated and contracted. Hoffinger has shown that the absorptive power of the peritoneum is greatly increased by massage. In experiments upon rabbits, the peritoneum was found to absorb under the influence of massage twice as much water in an hour as without massage. An experiment made by Mosengeil, an eminent German physiologist, graphically demonstrates the influence of massage in promoting absorption. The joints of rabbits were injected with ink. Massage was applied to some of the rabbits and not to others. In the cases subjected to massage, the swelling which was produced by the injection rapidly passed away. When the rabbits were killed, some months afterward, it was found that the ink had entirely disappeared from the joints which had been masséed, and was found in streaks between the muscles, and accumulated in the lymphatic glands, indicating the course of the lymphatic channels. In cases in which the joints were not masséed, ink was found in the joints, but none in either the muscles or lymphatic glands. This result affords a striking illustration of the value of massage in affections of the joints accompanied by exudate. It is through its power to promote absorption that massage is of great value in the treatment of local edema, general dropsy, and ascites. Effects of Massage upon Respiration.— These effects may be thus enumerated :— 1. Increase of Respiratory Activity.—Massage, as does exercise, increases the depth of the respiratory movements. This is  doubtless in some measure due to the reflex influence of massage, but must also be attributed in part to its effect in bringing into the circulation waste products requiring elimination through the lungs, and in increasing oxidation, or CO2 production, which necessarily accompanies the increased heat production resulting from the effect of massage upon the muscles. 2. Increase of Tissue Respiration.—It should be borne in mind that the function of respiration is not confined to the lungs. Respiration begins and ends in the lungs, but the most important part of the process is effected in the intimate recesses of the tissues themselves. Massage is certainly a most efficient means of increasing tissue metabolism, by which oxygen is absorbed by the tissues and CO2 taken up by the blood. This process takes place chiefly in the muscles, through the oxidation of the glycogen, of which they contain one half the total bodily store. Hence it is that massage, by acting directly upon the muscles, increases the tissue respiration by promoting circulation and general tissue activity. In thus promoting the depth of respiratory movement and the intensity of tissue respiration, massage profoundly affects all the bodily functions. Through the increased lung activity there is also increased circulation, as the lungs materially aid the heart in the circulation of the blood. Increased activity of the diaphragm serves to pump both blood and lymph toward the heart with greater vigor. Digestion, liver action, and other of the vital functions come in for their share of benefit in the increased vigor and efficiency of the respiratory process. The functions of the brain are more easily performed on account of the more perfect movement of venous blood and the better supply of oxygen received. Influence of Massage upon the Heat Functions of the Body. —  The heat functions of the body being so intimately connected with the circulation and general tissue activity, it is clear that any agent which profoundly affects the latter must also affect the former proportionately. The heat functions consist of three distinct processes,— heat production, heat elimination, or dissipation, and heat regulation. Massage materially influences all three of these processes. The muscles are the chief seat of heat production in the body, containing a great store of glycogen and a special mechanism which, under the influence of the nervous system, gives rise to increase or decrease of oxidation, or combustion of the glycogen. The muscles may be considered as the furnace of the body. During activity, heat production is very active; while during rest, it is considerably diminished. In fever there may be either a great increase of heat production or simply a loss of heat regulation, or both conditions may exist. It is thus evident that those procedures of massage which especially concern the muscles, such as different forms of deep kneading and strong percussion, must exert a powerful influence upon heat production. By actual observation it has been shown that massage of a muscle, as well as exercise, may cause a rise of temperature amounting to several tenths of a degree Fahrenheit. The importance of this fact will be recognized when it is recalled that four fifths of all the food eaten goes to the production of heat, only one fifth of the force represented in the food reappearing as work or energy. This explains the enormous increase of CO2 in connection with muscular exercise. The quantity of CO2, eliminated during vigorous muscular effort sometimes rises to nearly five times the usual amount. Muscular waste and weakness in fever is chiefly due to the consumption of the glycogen, which occurs under the influence of the toxic substances present in the tissues during febrile states.  The continued activity of the muscles in heat production, even when the body is at rest, is doubtless due to the slight muscular activity constantly present as so-called muscular tone. Winternitz has shown that under some circumstances heat elimination by the skin may be nearly doubled (increased ninety-five per cent) by friction. He accordingly recommends friction, in connection with the cold bath, for reducing temperature in fevers. Celsus, the famous old Roman physician, recommended rubbing in fevers when the surface was cold, although be carefully interdicted rubbing in fevers at other times. The increased heat dissipation resulting from massage is directly due to the increased circulation of blood in the skin. The higher the temperature of the skin the more rapid will be the dissipation of heat from the body. The skin is the principal means by which the blood is cooled, the heat brought from the interior to the surface being dissipated by radiation, conduction, and especially by the evaporation of water poured out of the skin by the sweat glands. Massage, by dilatation of the blood vessels and acceleration of the peripheral circulation, brings an increased quantity of heat to the surface, and at the same time, through increasing the blood supply and by reflex influence upon the sympathetic nerves, it induces increased activity of the sweat glands, which leads them to pour out an increased amount of perspiration. Thus heat dissipation is increased both by radiation and by evaporation as the result of the application of superficial massage. It thus appears that bodily temperature may be either increased or diminished by massage, since by kneading the muscles we may increase heat production, while by friction we may increase heat elimination. It is particularly important to remember that when massage is applied for the purpose of increasing heat dissipation, only such procedures should be adopted as will act upon the surface alone, since any manipulation of the muscles will increase heat production. A small amount of heat is communicated to the surface by the hand of the manipulator, and a further small quantity is generated by the friction of the hand upon the surface; but these sources of heat are too small to deserve more than mere mention. Another point worthy of notice is the fact that while general massage increases heat production, it does not necessarily increase the bodily temperature, for the reason that the increase in heat production may be more than balanced by the increased dissipation of heat. For example, in a case in which general massage increased the surface temperature 1.4 °F., the rectal temperature fell 0.8°F. Abdominal massage, however, exercises an effect the opposite of that of general massage. Massage of the abdomen may cause a fall of surface temperature of 0.2°F., while the rectal temperature rises 2.2°F. Effect of Massage upon Digestion.— There is no single function which may be more clearly demonstrated to be directly encouraged by massage than digestion. By its judicious application, the digestive process is promoted in several ways :— 1. By Improving the Appetite.—The general improvement in nutrition occasioned by the removal of waste and the acceleration of the blood and lymph circulations, creates a demand for an increased supply of nutriment which nature manifests by an improvement in appetite. 2. By Promoting Secretion of the Digestive Fluids.—Massage, especially abdominal massage, through its reflex influence upon the glands and circulation of the stomach and intestines, promotes the production of the digestive fluids in sufficient quantity and quality. 3. By Promoting Absorption of the Products of Digestion.—Hopadze has shown that massage of the abdomen, for even so short a time as ten minutes, applied at once after eating, diminishes by fifteen to seventy-five minutes the length of time the food is retained in the stomach. Hirschberg declares that massage of the abdomen hastens the passage of food from the stomach even more efficiently than does either exercise or electricity. This fact the writer has frequently demonstrated. 4. By Aiding Peristalsis.—Massage not only aids the absorption of food from the stomach, and its passage from the stomach into the intestine, but also excites the reflexes by which, the alimentary mass is moved along in the small intestine to the colon, and finally discharged from the body. Indeed, massage has no rival in its efficiency as a means of promoting intestinal activity. Influence of Massage upon Nutrition, Hematogenesis, and Phagocytosis.— That massage encourages the blood-making process is demonstrated by the rapidity with, which the number of red blood corpuscles and the amount of hemoglobin increase in the blood under the influence of this therapeutic means in cases of anemia. The value of this fact can scarcely be over- estimated. The blood is one of the most important of all the tissues of the body. The total amount of blood contained in the body is about ten pounds, each cubic millimeter of which contains from four and a half to five million corpuscles, making in all 32,500,000,000,000—more than twenty thousand times the entire population of the globe. These little bodies have a combined area of nearly 2900 square meters, or more than 3100 square yards—equal to a square nearly 175 yards on each side. When we consider that this enormous area of blood must pass through the lungs every twenty-two seconds in order to secure the proper amount of oxygen for the tissues, it is readily apparent how great a loss must be suffered when the quantity of blood is diminished ten to twenty or even seventy-five per cent, as in cases of anemia, and also the great gain effected by a like increase in the number of corpuscles, or oxygen carriers. Another important influence of massage upon the blood which has recently been noted is the immediate increase in the number of corpuscles produced by a general application of massage. Winternitz pointed out, several years ago, the interesting fact that by the application of cold water to the surface in such a way as to secure vigorous reaction, the number of corpuscles could be immediately increased from twenty-five to fifty per cent. In one case an increase of more than 1,800,000 corpuscles was noted within half an hour after the administration of the cold bath. Winternitz also showed that exercise has a like effect, and Mitchell, of Philadelphia, has proven the same for massage, and the author has confirmed the observation.  It is not to be supposed, as is remarked by Winternitz, that this sudden increase of blood corpuscles is due to a new production of blood cells ; the apparent increase in numbers is due to the sudden bringing into the circulation of a great number of corpuscles which had previously been retained in the large vascular viscera of the interior of the body, especially the spleen and liver. Quincke has noticed that the corpuscles accumulate in the capillaries of the liver and spleen in great numbers just before they are disintegrated, which naturally leads to the suggestion that the corpuscles set free by massage, and restored to usefulness by being brought into circulation, are at the same time rescued from destruction by the organs devoted to this work in the body. Some experiments conducted under the author’s direction for the purpose of determining the influence of massage upon the blood, show an increase of from three to seven per cent in the red cells, and from forty to eighty per cent in the white cells. The increase in the blood-count usually became apparent within thirty minutes, and lasted from an hour and a half to two hours. When massage is applied to persons in health , the effect upon the blood-count is, of course, temporary, but when the application is made to persons whose blood-count is deficient, the increase continues for several hours; and if the application is repeated daily, there will be noted a permanent increase in the blood-count from day to day. In this regard the effect of massage is precisely the same as that of cold applications. By the combination of these two potent measures,—short cold applications followed by massage,— the composition of the blood may be more rapidly and favorably influenced than in any other known way. Phagocytosis.—This interesting phenomenon, the complete demonstration of which was worked out by Metchnikoff in Pasteur’s laboratory, is influenced by massage to a remarkable degree. In the case of exudates in parts which have suffered from inflammatory processes, the removal of the exudate depends first upon its solution. This is effected by the white blood-corpuscles, which actually digest the inflammatory products, thus setting them free so they can be carried off by the venous and lymph currents. Phagocytosis is also the principal means by which the body antagonizes an invasion of foreign microbes which always takes place in connection with infectious disease. Microbes of various sorts, and even animal parasites such as the plasmodia of malaria, are captured and destroyed by the white blood corpuscles. It is, indeed, through the action of these blood cells that the vital current is kept free from foreign matters of various kinds. They seem to be, in fact, a sort of vital patrol which march up and down the highways of the body, resisting and destroying intruders of various sorts. It is evident that massage, as already pointed out by bringing into circulation an increased number of blood cells, must greatly increase the resisting powers of the body. It is especially worthy of notice that while both the red and the white corpuscles are greatly increased by massage, the white corpuscles are increased in much greater proportion than the red ones. Massage is also valuable as a regulator of the nutritive processes. Hopadze has proven that massage increases the assimilation of nitrogenous food substances, while Zabludowski has shown that massage both diminishes the weight of very fleshy persons and increases the weight of badly nourished persons, giving increased appetite and sleep. He showed that these effects continue not only during the treatment but for some time afterward. Influence of Massage upon Elimination.— The chief effects of massage upon elimination are:— 1. To Improve Elimination.—In general it sets waste matters free, by encouraging oxidation, by encouraging cell exchanges by which the waste matters are poured into the blood and the lymph currents from the tissues, and by stimulating the flow of the venous blood and the lymph, as well as by promoting general activity of the circulation, thus bringing the waste  matters in contact with the organs devoted to their elimination. 2. To Encourage Activity of the Liver.—The liver requiring oxygen in the various branches of its work as an eliminative organ, its action is greatly encouraged by the increased amount of oxygen brought into the blood by massage. The increased activity of the portal circulation produced by abdominal massage especially aids the liver. Hepatic activity may also be directly stimulated by the application of massage to the liver-especially by vibratory movements and percussion applied over the organ. The fact is worthy of notice that not only hepatic activity but renal efficiency depend upon the integrity and activity of the hepatic cell, which, when stored with glycogen, is capable of transforming leucomaines and various other toxic substances normally produced in the body, into less toxic forms, preparing them for elimination by the kidneys, and also actually destroying ptomaines and other alkaloids which may be taken in with the food or generated in the alimentary canal. Massage, by promoting these important activities in the liver, not only aids elimination through both liver and kidneys, but contributes to purity of blood by the destruction of poisons. 1. To Encourage Renal Activity.—That massage aids renal, activity has been actually demonstrated by experiments upon both dogs and human beings. Abdominal massage frequently gives,.rise to, a copious discharge of newly formed urine, although massage of the back or loins does not produce the same effect. Abdominal massage doubtless promotes kidney activity through its influence upon the lumbar ganglia of the abdominal sympathetic and the solar plexus. In experiments made upon a dog, it was observed that massage of the legs also promoted renal activity. The increased secretion of urine was, however, observed to be but temporary, probably because the quantity of fatigue-poisons in the body, the removal of which was especially aided by massage, was soon exhausted. It was found that the same effect was again noticeable after tetanizing the leg, whereby a new quantity of fatigue- poisons was produced. 1. To Promote Activity of the Skin.—The activity of the skin is promoted by massage, both in the direct stimulus of the sweat and sebaceous glands and the hair follicles, and also in the reflex influence upon the vasomotor nerves whereby an increased supply of blood is brought to the skin, thus promoting and continuing the glandular activity directly excited. An evidence of this stimulation of the skin as the result of massage is to be seen in the reddening of the surface; the increased perspiration, which may be so great as to interfere with the manipulations; the increased production of oil, which is particularly noticeable in cases in which the skin is abnormally dry at the beginning of a course of treatment; and the increased growth of hair, especially upon the legs and arms. Winternitz has shown that friction of the skin increases the elimination of water sixty per cent. When it is remembered that the skin is an organ of respiration as well as perspiration, its increased activity must be regarded as one of the most valuable effects of massage. It is also noticeable that massage of the skin increases its reactive power and so gives it increased ability to defend itself against changes in temperature, weather changes, etc. Local Effects of Massage.— The local effects of massage may be briefly stated to be:— 1. Increase of blood and lymph circulation. 2. Increase in both constructive and destructive tissue change. 3. Absorption of waste or effused products. 4. Development of the muscles, ligaments, and other structures acted upon. 5. Increased heat production and tissue respiration. 6. Reflex or sympathetic effects upon the vasomotor centers, and through them upon the large internal organs,-the liver, spleen, stomach, intestines, kidneys, and the general glandular system of the whole body.  The Therapeutic Applications Of Massage As it is not the purpose of this work to enter into an exhaustive consideration of all the different applications of massage. we shall scarcely do more than mention briefly those maladies in which this therapeutic measure has been found most conspicuously useful. It is, in fact, hardly necessary to devote any very great amount of space to the general considerations which alone may be appropriately treated of under this head, since the concise résumé of the physiological effects of massage which has already been presented, will, for the intelligent practitioner, serve as the best possible index to its therapeutic applications ; while for the masseur, the more specific directions given in connection with the individual measures of massage will be of greater practical use. Disorders of Nutrition.— Ancient as well as modern physicians have regarded massage as a measure by which the general nutritive processes of the body may be influenced in a most powerful degree. The value of massage as a therapeutic means arises from its remarkable influence upon the circulation the direct and indirect stimulation of the nerves and nerve centers and its remarkable modifying influence upon assimilation, disassimilation, and all the processes of secretion and excretion. Anæmia and chlorosis are more rapidly and permanently cured by massage than by any form of medication which has been proposed. In connection with a properly regulated dietary and suitable hydropathic measures, massage must be considered as the treatment par excellence for these maladies. The writer has seen excellent results in a number of cases of myxœdema in which massage was the leading therapeutic agent employed. If not capable of effecting a radical cure in this disease, it must at least be accredited with the power to prevent a further advance of the malady, and as a means of securing a very decided symptomatic improvement. In cases of exhaustion from excessive mental, nervous, or muscular work, general massage secures the most marked and satisfactory results, relieving the sense of fatigue in a most wonderful manner, and in cases of muscular exhaustion, restoring muscular power in a remarkably short space of time. Massage also exerts a decidedly quieting influence upon the nervous irritability and insomnia so commonly accompanying cerebral and nervous exhaustion The restorative effects of general massage act with much efficiency as a means of retarding the encroachments of old age, as well as in relieving the infirmities incident to that period. It may be justly considered as a very excellent means of prevention against arteriosclerosis, especially if employed in conjunction with suitable exercise. Diathetic Disorders.—While not a substitute for regimen in the treatment of those maladies having their foundation in a morbid diathesis, of which obesity, chronic rheumatism, and diabetes are the three leading types, massage is certainly a valuable adjunct in the management of this important class of disorders. It is of special value in the treatment of obesity, particularly at the beginning of a course, when the patient is too feeble muscularly to undertake the active exercises necessary to effect a change in his nutritive processes. Massage is equally useful in cases of rheumatism in which exercise is impossible in consequence of pain, stiffness, or deformity, and also as a means of relieving pain occasioned by the first attempts at exercise. Of equal value is massage in the treatment of diabetes accompanied by great weakness or exhaustion, rendering the amount of exercise necessary for the burning up of the surplus sugar impossible to the patient on account of the feeble condition of his nervomuscular apparatus. Finkler reports a large number of cases of diabetes mellitus in which great improvement was secured by massage. Zimmer has shown that vigorous muscles, even when at rest, destroy more sugar than do feeble ones, a fact which is easily understood when we remember that the muscles are the furnace of the body, and are the chief seat of the vital combustion by which glycogen, or sugar, is consumed. Large and vascular muscles will naturally consume more sugar than feeble and anaemic muscles, just as a large furnace with a good draft will consume more fuel than a small furnace with a poor draft. Under the influence of either massage or exercise, the blood is made to go through the muscles; while in a state of rest it goes round rather than through them. Bouchard also has shown that exercise of the muscles increases the consumption of sugar, and thus diminishes the amount of sugar found in the urine in cases of diabetes. I have often had opportunity to confirm this observation in my own experience in the treatment of this disease. In the treatment of muscular rheumatism, massage not only relieves the pain accompanying the disease, but also antagonizes the muscular atrophy which is one of its most constant results. In the treatment of articular rheumatism, massage relieves the pain through its derivative action, and also promotes the absorption of effused inflammatory products, and restores lost mobility. Other observers as well as the author have found massage useful in arthritis deformans, and it has given excellent results in the arthritic neuroses, which are so often the result of acute or chronic inflammation, and injuries to the joints. The consecutive or secondary fatigue which is so apt to occur in the employment of exercise in these maladies is more readily relieved by massage than by any other means. Disorders of the Circulatory System.— Oertel has employed massage of the heart in cases of cardiac weakness with great success. Massage and joint movements are of special advantage in cases of chronic diseases of the heart, by aiding the circulation and thus relieving the heart of a portion of its work, whereby it is afforded an opportunity to rally and its nutrition is improved. Centripetal friction of the extremities is the most powerful of all means of aiding the venous and lymphatic circulations in œdema and allied conditions. When the heart and blood vessels are excessively active, as after violent exercise, the circulation may be quieted by centrifugal friction. This measure is useful in cases of insomnia from cerebral congestion, overcompensation through excessive development of the heart muscle as the result of valvular disease, or obstruction to the pulmonary circulation arising from disease of the lungs. In Raynaud’s disease, or local asphyxia, massage affords a measure of treatment of great importance. There is, in fact, no single means which can be relied upon as of greater value than local massage systematically employed in the management of this very remarkable malady. Diseases of the Muscular System.— Although disease of the muscles is usually accompanied by disorder of the controlling nerves, the application of massage directly to the muscles is of the highest value in the treatment of most cases of muscular paralysis and paresis. In spasmodic diseases, such as chorea, most excellent results have been obtained through the improvement of the muscular tone resulting from suitable applications of massage, especially when combined with gymnastics. In muscular atrophy, whether resulting from neuritis or from disease of the cord, massage of the muscles, especially friction and petrissage, is a measure of the highest value , affording, in fact, the best of all known means by which the nutrition of a muscle may be maintained while regeneration of the connecting nerve structures is taking place. Even in fatty degeneration of the muscles, massage may still prove of value. It is not to be expected, of course, that muscles which have undergone complete fatty change will be regenerated; but through the increased nutritive activity set up by judiciously administered massage, those muscular fibers remaining intact may be developed to such an unusual degree that they are able to perform in a very satisfactory manner the functions of the entire muscle or muscular group. In pseudohypertrophy of the muscles, massage furnishes the most satisfactory of all means of combating the morbid process which, left to itself, ultimately results in tissue degeneration and corresponding loss of function. Diseases of the Nervous System.— There is certainly no class of disorders in which massage has won greater triumphs than in diseases of the nervous system, especially those which are purely functional in character. In the various forms of neurasthenia, massage has, in connection with a suitable regimen, often accomplished results little less than marvelous, as is illustrated not only by the cases published by S. Weir Mitchell, who first systematized the use of massage in this class of nervous disorders, but also by the experience of hundreds of other physicians who have witnessed the effects of massage upon an emaciated, neurotic invalid, when applied by a person thoroughly skilled in its employment. Chorea, writer’s cramp, blepharospasm, wryneck, and other maladies in which irregular muscular action, or spasm, is a leading symptom, are more amenable to this measure of treatment than to any other therapeutic means. Such other painful disorders as facial neuralgia, lumbago, sciatica, crural neuralgia, and even migraine, also yield to general and local applications, and often in a most surprising manner. The curative effect of massage in migraine is due to the fact that it may be employed in such a way as to influence the sympathetic as well as the central nervous system, since this disease has been clearly shown to be dependent upon a disordered state of the sympathetic, and probably in most cases to a disturbance of the abdominal sympathetic. In rare cases there are found in connection with the disease, and apparently sustaining a causative relation to it, points of induration or thickening in the trapezius and scaleni muscles. Massage locally applied is of special benefit in cases of this kind.  The various forms of headache are in a high degree amenable to treatment by general and local applications of massage, especially the different forms of headache from which neurasthenic and anaemic individuals so commonly suffer. Even in the treatment of neuritis, massage proves a serviceable measure, provided it is properly employed. It must, of course, be used derivatively in the first stage, and be wholly suspended in the second stage of the disease, while in the third stage, direct and vigorous applications are most effective. Anæsthesias, hyperæsthesias , and the various forms of paræsthesianumbness, tingling, crawling, burning, prickling, and other morbid sensations when of functional origin, quickly yield to suitable applications of massage. Even such structural maladies as locomotor ataxia, spinal sclerosis, infantile paralysis, and progressive muscular atrophy, not infrequently make more improvement under massage than can be secured by any other means. The writer has seen, in cases of this sort, results which were truly surprising, and far beyond the most sanguine expectations. Disorders of the Digestive Organs.— In the treatment of the various forms of indigestion, massage, general and local, is second in value only to diet and hydrotherapy. In certain classes of cases, indeed, massage can hardly be said to be second to the important therapeutic agents mentioned, especially in cases in which dilatation of the stomach, prolapse of the stomach or bowels, or other mechanical or static derangements of the viscera are chiefly responsible for the symptoms present. We need not dwell further upon this point, however, as the application of massage in this class of disorders is considered at length elsewhere in this work. Diseases of the Liver.— Although the liver is one of the most important organs concerned in the digestive function, it performs so many and such varied functions that it is proper to consider it by itself. While organic diseases of the liver are only to a very slight degree benefitted by massage, nearly all its functional disorders are capable of being very directly and beneficially influenced by appropriate applications of massage and joint movements. In acute inflammatory affections of the liver, massage and joint movements of the legs, carefully administered, are of great value as a means of relieving the general visceral congestion which results from hepatic inflammation, as well as the congestion of the liver itself. In those conditions of the liver commonly termed torpidity, or sluggishness, massage of the liver itself is a measure of the greatest value. Vigorous percussion over the region of the liver, and kneading of those portions of the organ which are accessible to the hand of the masseur, are of very great value; but even greater value must be attached to general abdominal massage and chest massage combined with breathing movements, by which the stagnating circulation of the liver may be accelerated. In cases of gallstones, massage has often proved a valuable measure, furnishing a means whereby the gall bladder may be made to discharge its contents into the intestinal canal. Manipulations of this sort must be employed with the greatest discretion, however, and should be trusted only to the hands of a trained masseur acting under intelligent medical direction. Renal Disease.— Massage is undoubtedly of value in the treatment of certain forms of renal disease, although in this class of cases it is necessary that it should be used with great care and discretion. This is especially true as regards acute inflammatory conditions of the kidneys, in which the throwing into the circulation of a great quantity of waste mattersleucomaines—by means of massage, might overtax the disabled kidneys. Massage affords an excellent means of relieving the œdema sometimes present in renal disease, although, of course, it is not to be expected that a radical cure will be effected in all cases of this sort.  In displacement of the kidney massage locally and skillfully applied is of paramount importance, and in cases of renal insufficiency, massage may often be used with excellent results. Disorders of the Pelvic Organs.— In diseases of the uterus and ovaries, massage often affords relief which cannot be obtained by any other means. While cures can seldom be expected in cases of chronic retrodisplacement, displaced ovaries may often be restored to position by skillful manipulation; and even in cases in which the uterus and ovaries cannot be permanently replaced, so great improvement in the nutrition of the parts may be effected by massage as to relieve the patient from the distressing symptoms which had previously made life miserable. Employed in connection with hydrotherapy, especially the sitz bath, the vaginal douche, and the moist abdominal girdle, with judicious applications of electricity and carefully graduated exercise, general and local massage may often be made to secure the most wonderful results. It is almost always necessary as a supplementary mode of treatment in cases in which an operation has been performed for shortening the round ligaments as a means of correcting retrodisplacement. The neglect to employ massage and other curative means in these cases often results in failure to accomplish what might, otherwise be effected in a most satisfactory manner, in the relief of this most obstinate, and with ordinary means incurable, class of maladies.  Amenorrhœa and dysmenorrhœa are often more effectively treated by massage than by any other therapeutic means. Massage is useful not only in cases in which the menstrual pain is due to a morbid condition of the uterus, but also in ovarian dysmenorrhœa. In the latter class of cases, indeed the writer has witnessed the most satisfactory and even remarkable results. Subinvolution, and many other morbid conditions following childbirth, are most efficiently treated by pelvic massage. Among intelligent medical practitioners, massage of the breast has almost wholly replaced the old fashioned breast pump, which has been responsible for so much mischief in cases requiring artificial emptying of the breast in nursing women. Massage of the prostate has afforded valuable results in certain cases of recent enlargement of this organ as the effect of inflammatory action. In chronic enlargement from hypertrophy, however, very little result can be expected. Spinal Curvatures.— In the treatment of spinal curvatures , massage is an extremely important adjunct to exercise and electrical applications, although it can hardly be said to be a substitute for either of these. By the combination of these three remedies, however, results which seem little less than marvelous may be obtained in suitable cases, but little can be expected when fatty degeneration of the muscles and structural changes of the vertebræ have taken place. In the lastnamed cases, mechanical support of some kind must be employed. Pulmonary Disorders.—Massage is of value in various forms of pulmonary disease, especially in chronic pleurisy accompanied by serous exudate. Poliakow reports most excellent results in the treatment of cases of pleurisy with exudation, absorption having taken place in eight to twenty days in each of the ten cases treated by this method. In the application of massage to the thorax to promote absorption, the manipulations should be in the direction of the lymphatics, which run toward the axilla. All of the different procedures of massage of the chest should be employed, but special attention should be given to friction and hacking movements. Massage, in cases of this sort, is much to be preferred to blisters and other forms of counterirritation, for the reason that the mild effects which it produces may be daily repeated, and it is accompanied by other results of even greater importance. In emphysema, massage may be so employed as to relieve pulmonary congestion and aid expiration. In phthisis the writer has seen excellent results from the use of massage, but it should be remembered that massage, as well as exercise, must be suspended during febrile conditions, as the heatregulating functions of the body are seriously interfered with in phthisis as well as in acute febrile states. Massage, administered in such conditions, will increase the production of heat, and out of all proportion to the vigor of the treatment, just as so slight an amount of exercise as sitting up in bed will sometimes produce a relapse in cases of typhoid fever after convalescence is well established. The only form in which massage can be employed with advantage, or without risk of injury, is that of light friction. Both centripetal and centrifugal friction , may be employed. As a rule, centrifugal friction should conclude the seance in all cases in which there is so slight an amount of temperature rise as one or two degrees Fahrenheit, and the patient should rest for at least two hours after the treatment. The best time of day for applying massage in cases of pulmonary disease, is soon after breakfast, or before the daily temperature rise begins. Massage of the chest is especially useful. Sprains and Fractures.— The general plan to be pursued in the employment of massage in the treatment of fractures is the following: When the fracture is reduced, place in an immobilizing apparatus. After three or four days, remove each day and apply massage to the whole limb, taking care to avoid displacement of the fragments. After the massage the splints or other immobilizing apparatus must be carefully replaced. The massage of the portion of the limb adjacent to the fracture should at first be very gentle, consisting of centripetal friction and fulling movements, the pressure being gradually increased from day to day, deep massage being introduced not later than eight or ten days from the, date of the fracture. Light percussion of various sorts may be applied to the whole limb. Deep massage may be applied to the uninjured portions of the limb from the start. The author has found it advantageous to use hot fomentations and alternate hot and cold compresses in connection with massage. At each treatment, the joints which are confined by the splints should be carefully flexed, so as to maintain perfect mobility. The attention of the profession has been especially called to the value of massage in fractures by Schode, Mezger, LucasChampionnière, and Berne. Diseases of the Eye and Ear.— Muscular asthenopia, glaucoma, corneal ulcer, corneal opacity, and various other, affections of the eye, have been successfully treated by massage. Certain forms of deafness, particularly deafness due to catarrhal disease of the Eustachian tubes, may be not only temporarily relieved but permanently benefitted by massage of the ear, neck, and throat ,. Even acute and chronic nasal catarrh is improved under careful applications of massage to the face and neck.  The Procedures Of Massage All the different useful procedures in massage may be classified under seven heads, as follows: Touch. Stroking. Friction. Kneading. Vibration. Percussion. Joint Movements. Under each of these heads we have several subdivisions, which must be separately considered. Touch The touch of massage is not simply an ordinary touch or contact of the hand with the body, but is a skilled or professional touch. It is a touch applied with intelligence, with control, with a purpose; and simple as it is capable of producing decided physiological effects. This procedure has three different forms of application ; viz., passive touch, pressure, and nerve compression. Passive Touch (Fig. 34).—This consists in lightly touching the part operated upon with one or more fingers, with the whole hand, or with both hands. Physiological Effects.—The physiological effects of simple touch are :— 1. Elevation of the temperature of a part by the communication of animal heat. 2. A subtle influence upon the nervous system-the so called  hypnotic effect, not due to any occult force exerted or mysterious qualities possessed by the operator, but simply the reflex influence through the cutaneous nerves upon the centers of the brain and cord, of the gentle contact of a warm, soft hand with the skin. 3. It is possible that certain electrical effects may result from simple contact of the hand of the masseur with the body of the patient. The effects of simple touch are quite remarkable. Some persons seem to be especially sensitive to its effects, and feel, or imagine they feel, a peculiar influence emanating from the operator, to which the term “magnetism” has sometimes been applied. The hypnotic state is produced in some very susceptible individuals by, simple passive touch. The peculiar influence attributed to the touch of certain persons is due, not to any occult power, but to subtle qualities of manner, a peculiar softness of the hand, or some other personal quality not easy to describe. Therapeutic Applications.— Touch is often remarkably effective in relieving hyperæsthesias, especially in the region of the head and joints. Pain is lessened, and numbness, tingling, and other sensations are made to disappear. Sleeplessness may also be relieved, and nervous irritability quieted, by simple contact of the band with the head. In applications of touch for therapeutic purposes, it is important that the utmost quiet should be preserved. The patient should be required to shut his eyes, if the application is made for the relief of insomnia or general nervous irritability, and should not be allowed to speak, neither should he be spoken to. All noises and disturbing causes should be suppressed, as it is desirable that the patient’s mind should become as quiet as possible, and that the sensorium should be protected from the disturbing influence of sensory impressions of every sort. Pressure.— This consists in making light or heavy pressure with the whole of one or both hands or with one or more fingers, upon the head, a joint, or some swollen or irritated part, or upon any portion of the body. Physiological Effects and Therapeutic Applications.—The effect of pressure is to diminish swelling and congestion, and thus to relieve pain. Violent headache or pain in a joint may often be relieved in this way. A person suffering from severe toothache involuntarily makes firm pressure against the painful part. Pressure relieves pain, doubtless both by emptying the blood vessels and by benumbing the nerves. Nerve Compression (Fig. 35).— In this procedure strong pressure is made upon a nerve trunk at some point in its course. The points usually selected for pressure are the so-called “motor points,” which are located upon the surface where large nerve trunks are readily accessible, lying just beneath the skin. The accompanying cuts (Figs. 32 and 35) show at a glance the points at which the principal nerves may be most easily reached. The spinal nerves are compressed by placing one finger on each side of the spine and making firm pressure opposite the spaces between the vertebræ. Physiological Effects.— The physiological effect of light pressure upon a nerve trunk is that of stimulation. The slight irritation produced by the pressure is transmitted to the nerve centers