Popular Science Monthly/Volume 21/October 1882/Massage: Its Mode of Application and Effects
|MASSAGE: ITS MODE OF APPLICATION AND EFFECTS.|
By DOUGLAS GRAHAM, M. D.
"MASSAGE," from the Greek masso (I knead or handle), is a term now generally accepted to signify a group of procedures which are usually done with the hands, such as friction, kneading, manipulating, rolling, and percussing of the external tissues of the body, either with some curative, palliative, or hygienic object in view. Its application should in many instances be combined with passive, resistive, or assistive movements, and these are often spoken of as the so-called Swedish movement-cure. There is, however, an increasing tendency on the part of scientific men to have the word "massage" embrace all these varied forms of manual therapeutics, for the reason that the word "cure," attached to any form of treatment whatsoever, can not always be applicable, inasmuch as there are many maladies that preclude the possibility of recovery and yet admit of amelioration. Hence the. word "cure" may lead people to expect too much; and, on the other hand, the use of the word "rubbing" in place of "massage" 1 tends to undervalue the application and benefit of the latter, for it is but natural to suppose that all kinds of rubbing are alike, differing only in the amount of force used.
According to the requirements of individual cases, massage may be o primary importance or of secondary importance, of no use at all, or even injurious. Concerning the extent of its usefulness, it may with safety be said that, at tolerably definite stages in one or more classes of affections in every special and general department of medicine, evidence can be found that it has proved either directly or indirectly beneficial, or led to recovery, sometimes when other means had been but slowly operative, or apparently had failed altogether. In view of these facts, it need hardly be said that those who would properly understand and apply massage should be familiar with its past and present literature; they should also be familiar not only with the natural history of the maladies in which massage may be applied when left to themselves, but also with the course of these affections when treated in the usual approved methods, so that improvements or relapses may be referred to their proper causes. Moreover, they should know something about the methods of others who have any claim to respectability in their manner of applying massage, so as to compare them with their own. And yet all these qualifications may fail if the operator has not in addition abundance of time, patience, strength, and skill, acquired by long and intelligent experience. Measured by these requirements, I fear that good masseurs (manipulators) are scarce. Dr. E. C. Seguin, in the "Archives of Medicine" for April, 1881, says, that even in New York there are few manipulators who can be trusted to do massage well. Massage may be studied as a science, but it has, like everything else in medicine and surgery, to be practiced as an art. Those who have a natural tact, talent, and liking for massage, united with soft, elastic, and strong hands, and physical endurance to use them, may be as useful artists in this department of the healing art as in others. It has been well said that those who do massage should be tender and gentle, yet strong and enduring. These are qualities that are rarely found combined in manipulators. It is a very common mistake to suppose that those who are of a remarkably healthy, ruddy appearance, plethoric and fat, are the best fitted to do massage. Such people require a great deal of exercise in the open air for the proper oxygenation of their blood, and confining, in-door work, like massage, they soon find to be tedious and irksome. Besides, the stooping attitude and varying positions so often necessary while doing this sort of work soon put them out of breath; and thus, while suffering from their ignorance and awkwardness, they fancy they are imparting "magnetism" to their patients at their own expense. Better that the manipulators should be rather thin, though if of too spare a habit their hands will not be sufficiently strong and muscular and their tissues generally will lack that firmness necessary for prolonged endurance.
One of the best German medical reviews, "Schmidt's Jahrbücher," in an extensive report on massage, thus indicates the esteem in which this treatment is held by many eminent physicians and surgeons of Europe: "It is but recently that massage has gained an extensive scientific consideration, since it has passed out of the hands of rough and ignorant empirics into those of educated physicians; and upon the results of recent scientific investigations it has been cultivated into an improved therapeutical system, and has won for itself in its entirety the merit of having become a special branch of the art of medicine." Professor Billroth, one of the most eminent surgeons of Germany, in a lecture on this subject published in the "Wiener med. Wochen.," No. 45, 1875, says: "I can only agree with my colleagues, Langenbeck and Esmarch, that massage in suitable cases deserves more attention than has fallen to its lot in the course of the past ten years in Germany. . . . As practice in the manipulations, time, perseverance, and personal interest in the matter are necessary, and these one can not bestow who interests himself much in medicine and surgery, I have turned over to my old experienced surgical assistant suitable cases for massage, and he has already obtained a series of results both favorable and surprising, and far exceeding my expectations of this method of treatment." Previous to the past fifteen years the French physicians took more interest in massage than any others, but of late they have almost entirely laid it aside. With their waning interest the Scandinavians and Germans have taken up the subject with renewed zeal, and from time to time furnish instructive accounts of their experiments, successes, and failures.
How is massage regarded, and what is its condition, in the United States? Except among very few—epicures in this matter, if one may so speak—there is as yet but little evidence of a desire to place massage, and those who do it, on their merits alone, irrespective of the policy of employing persons who are only rubbing-machines, or of tolerating obnoxious individuals so long as the poor patients' minds are satisfied. This is too often the case, and then massage is said to have failed and valuable time is lost, when, if it had been properly applied, it might have been successful; or, on the other hand, perhaps it should have been omitted and other remedies employed. The writer of this, in a recent paper on the "History of Massage," has said: "In almost every city of the United States, and indeed of the whole civilized world, there may be found individuals claiming mysterious and magical powers of curing disease, setting bones, and relieving pain by the immediate application of their hands. Some of these boldly assert that their art is a gift from Heaven, due to some unknown power which they call magnetism, while others designate it by some peculiar word ending with pathy or cure, and it is astonishing how much credit they get for their supposed genius by many of the most learned people." Let a fisherman forsake his boat, or a blacksmith his anvil, or a carpenter his bench, or a shoe-maker his shop, and proclaim that he has made the wonderful discovery that he is full of magnetism and can cure all diseases, and, be he ever so ignorant and uncouth, he is likely to have, in a remarkably short space of time, a large clientèle of educated gentlemen and refined ladies. It is not meant to imply that the previous occupation of such people is at all to their discredit, but, were they capable of giving a rational explanation of their doings, the halo of mystery would be removed from around them, and their prestige and patronage would suffer a sudden decline.
In Boston and Philadelphia, and perhaps in other cities as well, efforts have been made by physicians, who are thoroughly familiar with massage, to instruct intelligent nurses and others how to apply it, and at the training-schools for nurses the pupils receive some general instruction in the matter. In this way something has been accomplished to bring massage within the rules and regulations of common sense and rational therapeutics. But still there is great room for improvement even in this direction, for it is but too often the case that after one or two persons are specially trained to do massage they are requested to give instruction to some of the pupils at the schools for nurses, and to others, a few of whom, after having received some general desultory lessons, are in turn delegated or relegated to teach others. and so on, until, by the time massage reaches the needy patients, there is often little left of it but the name. Hence it is not to be wondered at that many a shrewd, superannuated auntie, and others who are out of a job, having learned the meaning of the word massage, immediately have it printed on their cards, and keep on with their "rubbin'" just as they always have done.
The vaguest generalities exist as to the manner of doing massage, even among the best authors on the subject, and, after having studied and tried the methods of all, the writer proposes to briefly formulate, as much as space will permit of, what he has found to be of value, without having adopted the methods of any in particular. By so doing it is hoped that some will be able to judge whether those employed to do massage know anything about it or not, or whether it would not be as well to employ one of their own domestics for ordinary rubbing, the advantages of which are not to be despised. At any rate, from the description which follows, I trust that not a few intelligent friends of chronic invalids, who are beyond the reach of the professional manipulator, will be enabled to apply massage so as to afford even greater relief and comfort than can be gained from many of those whom the ignorance of the community on this subject alone tolerates as experts.
The multiform subdivisions under which the various procedures of massage have been described can all be grouped under four different heads, viz., friction, percussion, pressure, and movement. Malaxation, manipulation, deep-rubbing, kneading, or massage, properly so called, is to be considered as a combination of the last two. Each and all of these may be gentle, moderate, or vigorous, according to the requirements of the case and the physical qualities of the operators. Some general remarks here will save repetition: 1. All of the single or combined procedures should be begun moderately, gradually increased in force and frequency to their fullest extent desirable, and should end gradually as begun. 2. The greatest extent of surface of the fingers and hands of the operator consistent with ease and efficacy of movement should be adapted to the surface worked upon, in order that no' time be lost by working with the ends of the fingers or one portion of the hands when all the rest might be occupied. 3. The patient should be placed in as easy and comfortable a position as possible, in a well-ventilated room at a temperature of about 70° Fahr. 4. What constitutes the dose of massage is to be determined by the force and frequency of the manipulations and the length of time during which they are employed. A good manipulator will do more in fifteen minutes than a poor one will in an hour, just as an old working deliberately will accomplish more than an inexperienced one working furiously. Friction has been described as rectilinear, vertical, transverse or horizontal, and circular. It has been stated, and very properly, that rectilinear friction should always be used in an upward direction, from the extremities to the trunk, so to favor and not retard the venous and lymphatic currents. But a slight deviation from this method I have found to be more advantageous, for though in almost every case the upward strokes of the friction should be the stronger, yet the returning or downward movement may with benefit lightly graze the surface, imparting a soothing influence, without being so vigorous as to retard the circulation, and thus a saving of time and effort will be gained. The manner in which a carpenter uses his plane represents this forward-and-return movement very well. Transverse friction, or friction at right angles to the long axis of a limb, is a very ungraceful and awkward procedure. It has been introduced on theoretical considerations alone, and may with safety be laid aside, for the method already spoken of, together with circular friction, will do all and a great deal more than rubbing crosswise on a limb can do. A convenient extent of territory, to begin with, is from the ends of the fingers to the wrist, each stroke being of this length, the returning stroke being light, without raising the hand. The rapidity of these double strokes may be from one hundred to one hundred and fifty a minute. The whole palmar surface of the fingers should be employed, and in such a manner that they will fit into the depressions formed by the approximation of the phalang and metacarpal bones. The heel of the hand should be used for especially vigorous friction of the palm, as well as for the sole of the foot. From the wrist to the elbow, and from the elbow to the shoulder, are separately convenient extents of surface, and here not only straight-line friction, extending from one joint to the other, may be used, but also circular friction. The form of the latter which I have found most serviceable is in that of an oval, both hands moving at the same time, the one ascending as the other descends, at the rate of one hundred and twenty-five to two hundred and fifty each a minute, or two hundred and fifty to five hundred with both hands, each stroke reaching from joint to joint, the upward stroke being carefully kept within the limits of chafing the skin. These observations apply to the lower limbs also, but, as they are larger than the arms, the posterior and lateral aspects, from ankle to knee, will be a convenient territory, while the anterior and lateral aspects will be another for thorough and efficacious friction. The same systematic division of surface may be made above the knees as below, the number of strokes below will vary from one hundred to one hundred and sixty with each hand; above, from seventy-five to one hundred each. From the base of the skull to the spine of the scapula forms another region naturally well bounded for downward and outward semicircular friction, and from the spine of the scapula to the base of the sacrum and crest of the ilium forms another surface over which one hand can sweep, while the other works toward it from the insertion to the origin of the glutei, at an average rate of sixty or seventy-five a minute with each hand for a person of medium size. It will be observed that on the back and thighs the strokes are not so rapid as on the other parts mentioned, for the reason that the skin is here thicker and coarser, in consequence of which the hand can not glide so easily, and the larger muscles beneath can well bear stronger pressure; besides, the strokes are somewhat longer, all of which require an increased expenditure of time. The chest should be done from the insertion to the origin of the pectoral muscles, and the abdomen from the right iliac fossa in the direction of the ascending, transverse and descending colon. But here friction is seldom necessary, for the procedure about to be considered accomplishes all that friction can do, and a great deal more in this region. The force used in doing friction is often much greater than is necessary, for it is only intended to act upon the skin, and there are better ways of acting upon the tissues beneath it. If redness and irritation be looked upon as a measure of the beneficial effects of friction upon the skin, then a coarse towel, a hair mitten, or a brush would answer for this purpose a great deal better than the hand alone.
The most important, agreeable, and efficacious procedure of massage has been variously designated as manipulation, kneading, deep rubbing, or massage properly so called, in contradistinction to the more superficial method spoken of above. This is done by adapting as much as possible of the fingers and hands to the parts to be thus treated, and, without allowing them to slip on the skin, the tissues beneath are kneaded, rolled, and manipulated in a circulatory manner, proceeding from the insertion toward the origin of the muscles, from the extremities to the trunk, in the direction of the returning blood and lymphatic currents. For this purpose the same divisions of surface as for friction will be found most convenient. Beginning then with the fingers from the roots of the nails, the thumb of the manipulator will be placed on one of the fingers of the patient, and parallel to the latter, while on the opposite side the index-finger will be placed at right angles to this, and between the two the finger of the patient will be compressed and malaxated, in a rotary manner, at the rate of seventy-five to one hundred and fifty per minute. The dorsal and palmar surfaces will of course receive special attention, while the lateral aspects will come in for a secondary share. If the manipulator be sufficiently expert he can work with both hands on this small surface with the same rapidity as with one. Each finger and thumb will be taken in turn, and the manipulations extended over the metacarpal and carpal bones as far as the wrist-joint, and finally the palm of the hand by stretching the tissues vigorously away from the median line. Each part included in a single grasp may receive three or four manipulations before proceeding onward to the adjacent region. The advance upon this should be such as to allow the finger and thumb to overlap one half of what has just been worked upon. Advance and review should thus be systematically carried on, and this is of general application to all the other tissues that can be masséed. The force used here and elsewhere must be carefully graduated so as to allow the patient's tissues to glide freely upon each other; for, if too great, the movement will be frustrated by the compression and perhaps bruising of the tissues; if too light, the operators fingers will slip; and, if gliding with strong compression be used, the skin will be chafed. To avoid this last objection various greasy substances have been employed, so that ignorant would-be masseurs may rub without injuring the skin. When the skin is cold and dry, and the tissues in general are insufficiently nourished, as well as in certain fevers and other morbid conditions, there can be no doubt of the value of inunction; but no special skill is required in order to do this, and there is no need of calling it massage unless it be to please the fancy of the patient.
The feet maybe dealt with in the same manner as the hands, using the ends of the fingers to work longitudinally between the metatarsal as well as between the metacarpal bones. Upon the arms and legs, and indeed upon all the rest of the body, both hands can be used to better advantage than where the surfaces are small. Each group of muscles should be systematically worked upon, and for this purpose one hand can usually be placed opposite to the other and in advance of it, so that two groups of muscles may be manipulated at the same time. When the circumference of the limb is not great, the fingers of one hand will partly reach on to the territory of the other, while grasping, circulatory, spiral manipulations are made, one hand contracting as the other relaxes, the greatest extension of the tissues being upward and laterally, and on the fore-arms and legs away from the median line. Subcutaneous bony surfaces, as those of the tibia and ulna, incidentally get sufficient attention while manipulating their adjacent muscles, for, if both be included in a vigorous grasp, unnecessary discomfort results. Care should be taken not to place the fingers and thumb of one hand too near those of the other, for by so doing their movements would be cramped. The elasticity, or want of it, in the patient's tissues, should be the guide, the object being to obtain their normal stretch, and in this every person is a law to himself, the character of their tissues varying with the amount and quality of adipose, modes of life, exercise, etc. A frequent error on the part of manipulators is in attempting to stretch the tissues in opposite directions at the same time, especially at the flexures of the joints, where the skin is delicate and sensitive, and where the temptation to such procedures is greatest because easiest, the effect being a sensation of tearing of the skin. The rate of these manœuvres varies from seventy-five to one hundred and fifty with each hand per minute on the arms, from sixty to ninety on the legs, and from forty to eighty on the thighs, where more force is required on account of the larger size and density of the muscles, and the need of using sufficient force to extend beneath the strong, tense fascia lata.
On the back the direction of these efforts will be from the base of the skull downward, stretching the tissues away from the spinal column while manipulating in graceful curves at an average rate of sixty per minute with each hand. And here one hand can often be re-enforced by placing the other upon it, and thus massage may be done with all the strength the manipulator can put forth. With the ends of the fingers the muscles on each side of the spinal column can be rolled, and the supra-spinous ligament can be effectually massèed by transverse to-and-fro movements. The ends of the fingers and part of their palmar surface should also be placed on each side of the spinous processes, and the tissues situated between these and the transverse processes worked upon by up-and-down motions parallel to the spine, taking care to avoid the too frequent error of making pushing, jerky movements in place of smooth, uniform motions in each direction.
On the chest and abdomen the same general direction will be observed as in using friction, but the manipulation will be more gentle than on the back and limbs, for the tissues will not tolerate being so vigorously squeezed and pinched. Here the massage will consist of moderate pressure and movement with the palms of the hands, and rolling and grasping the skin and superficial fascia; and, after this, on the abdomen, steady, firm, deep kneading in the direction of the ascending, transverse, and descending colon, using for this purpose the greatest force with the heel of the hand on the side of the abdomen next the operator, and on the other side the strongest manipulations with the fingers, avoiding the frequent and disagreeable mistake of pressing at the same time on the anterior portions of the pelvis.
Before leaving this part of the subject, the writer begs leave to say something more about the common errors into which manipulators fall, even some of those who pass for being skillful. Many do not know how to do the kneading or malaxation with ease and comfort to themselves and to their patients, for, in place of working from their wrists and concentrating their energy in the muscles of their hands and fore-arms, they vigorously fix the muscles of their upper arms and shoulders, thus not only moving their own frame with every manipulation, but also that of their patients, giving to the latter a motion and sensation as if they were at sea in stormy weather. By this display of awkward and unnecessary energy, not only do they soon tire themselves, and say that they have lost magnetism by imparting it to their patients, but by the too firm compression of the patient's tissues they are not allowed to glide over each other; and hence such a way of proceeding entirely fails of the object for which it is intended. Surely, cultivation is the economy of effort.
Friction and manipulation can be used alternately, varied with rapid pinching of the skin and deeper grasping of the subcutaneous cellular tissue and muscular masses, and, when necessary, with percussion, passive, assistive, and resistive movements, finishing one convenient surface or limb before passing to another, and occupying from half an hour to an hour with all or part of these procedures. Pinching is used mainly to excite the circulation and innervation of the skin, and for this purpose it is best done rapidly at the rate of one hundred to one hundred and twenty-five per minute with each hand. To act on the subcutaneous cellular tissue, a handful of skin is grasped and rolled and stretched more slowly than by the preceding method. A deeper, momentary grasping of the muscles is often advantageous, and may be called a mobile intermittent compression, and this, indeed, is what the whole of massage, strictly speaking, consists of. Percussion, applicable only over muscular masses, may be done in various ways. In the relative order of their importance they are as follows: 1. With the ulnar borders of the hands and fingers. 2. The same as the first, with the fingers separated. 3. With the ends of the fingers, the tips being united on the same plane. 4. With the dorsum of the upper halves of the fingers loosely flexed. 5. With the palms of the hands. 6. With the ulnar borders of the hands tightly shut. 7. With the palms of the hands held in a concave manner, so as to compress the air while percussing. More gentle or vigorous and rapid percussion than any of these methods afford can be done by securing India-rubber air-balls on whale-bone or steel handles. With these one gets the spring of the handles together with the rebound of the balls, and thus rapidity of motion with easily varying intensity is gained, the number of blows varying from two hundred and fifty to six hundred a minute with both.
Remedial movements have been so well described in books on the so-called "movement-cure" that little need be said of them here. It is well for those who use them to know the anatomy and physiology of the joints and their natural limits of motion. Except in the case of relaxed joints, passive motion should be pushed until there is a feeling of slight resistance to both patient and manipulator; for by this will be known that in healthy joints the ligaments, capsules, and attachments of the muscles are being acted upon. Resistive movements are such as the patient can make while the operator resists. The opposing force should be carefully and instinctively kept within the limits of the patient's strength, and this, with all these other manœuvres, should stop short of fatigue. To alternately resist flexion and extension is the pons asinorum of manipulators, and, in a considerable experience of teaching massage, I have found but few who could learn to do it at all. Its importance can not be overestimated as a means of cultivating the strength of weakened muscles, while, at the same time, finding out how much they can be used. Many a patient who has recovered from an old injury is still as much incapacitated as ever, from the fact that his latent energies can only be discovered and made available in this manner. Midway between passive and resistive movements, in the course of certain recoveries, stand assistive movements. They are but little understood and seldom used. They may be illustrated as follows: Let it be supposed that, in the absence of adhesions and irreparable injury of the nerve-centers, the deltoid has but half the strength requisite to elevate the arm. So far as any use is concerned this is the same as if there were no power of contraction left in the muscle. But, if only the other half of the impaired vigor be supplemented by the carefully graduated assistance of the operator, the required movement will take place; and, in some cases, if this be regularly persisted in, together with manipulation and percussion, more vigorous contraction will be gained, and, by-and-by, the patient will exert three fourths of the necessary strength, and later the whole movement will be done without aid; and, as strength increases, resistance can be opposed to the movement. Partial loss of motion can often be accurately estimated by holding the limb suspended in a cloth attached to a spring-balance. When the patient makes effort the limb weighs less. By means of a spring-balance resistive motion can also be estimated. Still another kind of movement may be spoken of—namely, vigorous passive motion—with a view to breaking up adhesions in and about joints, a description of which does not come within the scope of this paper. It is the secret of success and of failure of the people who call themselves "bone-setters," the methods of whom have been well studied and explained by Dr. Wharton P. Hood, of London, in his very interesting book "On Bone-Setting, so called."
A description of massage of the head and the benefits that arise from it must be left to another time.
The relative importance of the foregoing procedures has been partly indicated while describing them. According to the needs of individual cases, one or more of these will predominate or be omitted, and it is well that the advice of a physician be sought on this subject, for there would be no use in giving a patient friction the capillary circulation of whose skin was already sufficiently good; and it would be a waste of time and strength to administer passive and resistive movements to patients who were already fatigued from overwork. To rouse the dormant action of cold skin and flabby muscle, percussion will be of the first importance, and will alternate with friction and manipulation. Percussion is in massage what faradization is in electricity, and will often answer the same purpose; manipulation, or deep-kneading, is to massage what the constant current is to electricity, and the ultimate effects of each are very much alike. In "Schmidt's Jahrbücher" and elsewhere numerous instances are given in which massage has succeeded, after electricity and other means had failed. The reverse of this may be true, but as yet I have not seen any proof of it. Let us now speak of the general effects of massage, and, further on, its influence more in detail. And, first, it may be well to premise that it requires, on the part of the patient a certain amount of latent energy, if one may so call it, in order to undergo even a minimum séance of massage; for a patient may be so weak as to preclude the possibility of its being applied without harm resulting. In properly selected cases, instances of which are frequently seen in individuals suffering from overwork, or want of work, worry, depression of spirits, and loss of sleep, together with feeble and tardy digestion—those who can not get or take rest, no matter how favorable the opportunity—the effects of massage are generally as follows: While it is being done, and often for several hours afterward, the patients are in a blissful state of repose; they feel as if they were enjoying a long rest, or had just returned from a refreshing vacation, and not a few say that it makes optimists of them for the time being. It produces warmth, comfort, and sleep; relieves or cures constipation, muscular pains, and stiffness. At the same time it exerts a peculiarly delightful and profound effect upon the nervous system, its influence being tonic, sedative, and physiologically counter-irritant, making more blood flow through the skin and muscles, and consequently less to the brain, spinal cord, and internal organs. To those to whom exercise would be injurious, massacre affords the advantages of exercise without exertion while the subjects of it are resting, their over-taxed will and used-up nervous energy not being required to express themselves in voluntary motion. For reasons such as these, we find no less an authority than the British "Journal of Mental Sciences" (for April, 1878) recommending "massage for certain melancholies, with trophic and vaso-motor affections, and also where dementia is threatened after an attack of excitement. Under this treatment mental comfort and a sense of well-being take the place of apathy and lassitude."
Lord Bacon has quaintly remarked that "repair is procured by nourishment, and nourishment is promoted by forwarding internal concoction, which drives forth the nourishment, as by medicines that invigorate the principal viscera; and, secondly, by exciting the external parts to attract the nourishment, as by exercise, proper frictions, etc." Massage excites the external parts to attract and assimilate the nourishment, brought thither by an increased volume of blood, and this, at the same time, favors absorption of the natural worn-out débris. The different ranks of the Sandwich-Islanders are of different stature; and we are told that the chiefs, though sunk in sloth and immorality, are not diminutive and decrepit, like many of their countrymen, for the reason that they fare sumptuously, take little or no exercise, and are lomi-lomied after every meal, in order to. aid their digestion and promote their circulation without inducing fatigue or exhaustion. Lomi-lomi is thus interestingly described by Nordhoff, in his book on "Northern California, Oregon, and the Sandwich Islands": "Wherever you stop, for lunch or for the night, if there are native people near, you will be greatly refreshed by the application of lomi-lomi. Almost everywhere you will find some one skilled in this peculiar, and, to tired muscles, delightful and refreshing treatment. To be lomi-lomied, you lie down upon a mat, or undress for the night, if you prefer. The less clothing you have on the more perfectly the operation can be performed. To you, thereupon, comes a stout native, with soft, fleshy hands, but a strong grip, and beginning with your head, and working down slowly over the whole body, seizes and squeezes with a quite peculiar art every tired muscle, working and kneading with indefatigable patience, until, in half an hour, whereas you were weary and worn out, you find yourself fresh, all soreness and weariness absolutely and entirely gone, and mind and body soothed to a healthful and refreshing sleep. The lomi-lomi is used not only by the natives, but among almost all the foreign residents; and not merely to procure relief from weariness, consequent upon over-exertion, but to cure headaches, to relieve the aching of neuralgic or rheumatic pains, and, by the luxurious, as one of the pleasures of life. I have known it to relieve violent headache in a very short time. The chiefs used to keep skillful lomi-lomi men in their retinues; and the late king, who was for some years too stout to take exercise, and was yet a gross feeder, had himself lomi-lomied after every meal, as a means of aiding his digestion. It is a device for relieving pain and weariness which seems to have no injurious reaction, and no drawback but one—it is said to fatten the subjects of it."
Dr. Weir Mitchell has successfully proved that many chronic invalids can be cured by rest and excessive feeding, made possible by means of massage and electricity. Under this combination of treatment, skillfully carried out, many become fat, strong, and well, thus illustrating the truth of Lord Bacon's remark, and the beneficial effects of the not very scientific massage of the Sandwich-Islanders. The lomi-lomi of the Sandwich-Islanders is only a series of intermittent squeezes proceeding toward the extremities, thus hindering the returning circulation; and this illustrates another fact—that many who have had but one kind of pinching and squeezing think it is "excellent" until they try some one who understands and can do it better; moreover, it shows that any sort of stirring up of the tissues is often better than none. In using massage, as much depends on the qualities and qualifications of the person who does it as in any other occupation. It would be wrong to leave the impression that massage is always agreeable from the first. In proportion as the muscles, superficial fascia, and skin are unnaturally tough, tense, matted and hide-bound, will the massage be disagreeable until they become soft, supple, and elastic. An appreciation of the proper consistence of the tissues and their anatomical structure is of the utmost importance for the success of this treatment.
But we must hasten to consider how massage acts locally. By upward and oval friction, with deep manipulation, the vein's and lymphatics are mechanically emptied—the blood and lymph are pushed along more quickly by the additional vis a tergo of the massage, and these fluids can not return by reason of the valvular folds on the internal coats of their vessels. Thus, not only is more space created for the returning currents arising from beyond the region masséed, but, at the same time, a vacuum is formed, which is visible in the superficial veins of persons who are not too fat; and this is thought by some to add a new force to the more distal circulation. In this way the collateral circulation in the deeper vessels is aided and relieved, as well as the more distal stream in the capillaries and arterioles. One would naturally suppose that the circulation in the larger arteries would, in this manner, be interrupted, and such is the case. But, herein comes an additional advantage to aid the circulation, for the temporary and momentary intermittent compression causes a dilatation of the artery from an increased volume of blood above the part pressed upon, and this accumulation rushes onward with greater rapidity as soon as the pressure is removed, in consequence of the force of the heart's action and the resiliency of the arteries acting upon the accumulated volume of blood.
But the same pressure also acts upon the tissues external to the vessels, causing a more rapid resorption of natural or pathological products through the walls of the venous capillaries and lymphatics. When muscular nerves are stimulated, the vaso-dilators are influenced, and this takes place by massage, whence follows enlargement of the lumen of the vessels, so that an increased flow passes through them with greater ease and diminished pressure. When stimuli are applied to the skin, reflex vaso-motor action shows that the vaso-dilators are acted upon, hence the redness and congestion of the skin when massage is specially directed to it. It can be readily seen now that massage rouses dormant capillaries, increases the area and speed of the circulation, furthers absorption and stimulates the vaso-motor nerves, all of which are aids and not hindrances to the heart's action, as well as to nutrition in general. Seeing that more blood passes in a given time, there will be an increase in the total interchange between the blood and the tissues, and thus the total amount of work done by the circulation will be greater and the share borne by each quantity of blood less. It will not be surprising, then, to learn that in practice massage sometimes proves a valuable ally in the treatment of functional and organic diseases of the heart, for "the peripheral friction of the blood against the walls of the capillaries and small arteries not only opposes the flow of blood through them, but, working backward along the whole arterial system, has to be overcome by the heart at each systole of the left ventricle." This obstacle is in great part lessened by massage. In exercise there is alternate contraction and relaxation of voluntary muscles, and this is a powerful aid to the circulation in general; for at each contraction the vessels are emptied by compression, and the alternating relaxation allows them to fill up again. Thus each muscle or group of muscles in activity has been appropriately likened to a beating heart. In this respect the intermittent pressure of massage aids and imitates the alternate contraction and relaxation of muscles very accurately, and no better praise could be bestowed upon any therapeutical agent than the old-fashioned, haughty, supercilious way of dismissing the subject of massage as unworthy of notice by saying that it was merely a substitute for exercise. Exercise favors all the functions, and people who can exercise freely without fatigue, and who can eat and sleep well, seldom need massage. I am aware that this statement includes many neurasthenics, especially those who suffer from want of occupation.
While undergoing massage it is well for the patient to take frequent and deep inspirations, in order to favor the flow of the venous and lymphatic currents to the thorax. This, however, is often instinctively done, and with such ease that the patient feels as if freed from an immense load. From a paper by Professor H. P. Bowditch, in the "Proceedings of the American Academy of Arts and Sciences," for 1873, "On the Lymph-Spaces in Fasciæ," we learn the following valuable and interesting facts: "In experiments on animals where the flow of lymph through the thoracic duct was measured, passive movements of the limbs increased this flow in a remarkable manner. Galvanization of the muscles had a similar but less powerful effect. The lymph-spaces existing between the tendinous fibers of fasciæ and the connection of these spaces with lymphatic vessels have been described by Ludwig and others. By virtue of this structure the fasciæ play an important part in keeping up the flow of lymph through the lymphatic vessels. A piece of fascia was removed from the leg of a dog and tied over the mouth of a glass funnel, with the side next the muscles uppermost. A few drops of a colored turpentine solution were then placed upon this surface, and the fascia alternately stretched and relaxed by partially exhausting the air from the funnel and allowing it to return again. In this way the coloring matter was made to penetrate into the spaces between the fibers of the fascia and to enter the lymph-spaces on the opposite side. The same result was obtained when the coloring matter was injected between the muscles and the fascia, and the latter stretched and relaxed by passive movements of the limb. The alternate widening and narrowing of the lymph-spaces between the tendinous fibers seems, therefore, to cause absorption of the lymph from the neighboring parts as well as its onward flow into the lymphatic vessels." This function of the fascia certainly affords a partial, important, and, so far as it goes, very satisfactory explanation of the success of methods of treatment which involve passive motion, for the removal of effete matters from the tissues is favored by an increased flow of lymph.
But Nature, as one of her regular functions, is continually performing this experiment in the voluntary and involuntary movements of the muscles. The large serous cavities, such as those of the pleura and peritonæum, are now regarded as extensive lacunae in the course of the lymphatic vessels; lymph-spaces and lymphatic vessels, communicating with each other by means of small openings or stomata, have been demonstrated in these membranes, and also the communication of the lymph-spaces with the pleural and peritoneal cavities by means of intercellular openings. This has been shown by injecting either of these cavities with colored fluid, and, after killing the animal, examining the course of absorption of the fluid under the microscope. In the movements of respiration, alternate expansion and contraction of the chest-walls, with descent and ascent of the diaphragm, we have a continual pump-like action of absorption and onward expulsion in the lymph-spaces and lymphatic vessels of the pleura and peritonæum. But we must not forget that the capillary blood-vessels are similarly influenced, nor should we fail to remember that osmosis may also play a very important part, and that this, too, can be increased by artificial pressure. We can now understand why the kings of the Sandwich Islands should be lomi-lomied after every meal in order to aid their digestion, for the externally applied pressure over the abdomen would force the contents of the lacteals, or lymphatics of the small intestine, onward, at the same time aiding them in their absorption of digestive products.
Professor von Mosengeil, of Bonn, has made some interesting and useful experiments by injecting the cavities of corresponding joints of rabbits with Indian ink, and in this way proving that resorption takes place from these cavities by means of lymph-spaces and stomata, communicating with lymphatic vessels, and through these with lymphatic glands. With each rabbit he masséed one of the joints and left the corresponding joint untouched. The swelling that arose from the injection always disappeared rapidly under massage, and, upon examination of the masséed joint, it was found emptied for the most part of its colored contents. Even when the examination was made shortly after the injection and the use of massage, there was proportionately little ink found in the joint, part of it was found upon the synovial membrane; and upon microscopic examination it was seen that the greatest part had been forced into, and had penetrated through, the synovial membrane, and the darkened lymphatics could be seen with the unaided eye from the injected joint to the lymphatic glands, and these latter were black from the absorption of the ink. Upon examination of the injected joint-cavities that had not been masséed, the ink was still found in the joint mixed with the synovia in a smeary mass, and it had not even penetrated into the tissue of the synovial membrane. With the removal of the effusion by the use of massage, Von Mosengeil always succeeded in improving the stiffness, and in obtaining the same appearances in the lymphatics.
From clinical experience in the use of massage in joint affections, such results as those obtained by Von Mosengeil might have been with safety predicted. A consideration of the mode of application of massage in joint injuries and affections, and its relations to mechanical support, rest, and exercise, would far exceed the limits of this paper. Scandinavian, German, and French army-surgeons, who with their own hands have used massage the most in joint maladies, have accumulated respectable and trustworthy statistics showing its great value in such cases. At the same time they have not forgotten to tabulate their failures. The result of their experience in recent joint injuries admitting of the application of massage is thus formulated: "It will simultaneously further and increase resorption, accelerate the circulation, relieve pain, and reduce elevated temperature" I have illustrated this by a report of over three hundred cases, the details of which may be found in the "New York Medical Record," No. 353. The "Nouveau Dictionnaire de Médecine" clearly expresses the action of massage in the following words: "Massage augments interstitial absorption not only by the sur-activité impressed upon the returning circulation, but also by dividing to infinity pathological and normal products accumulated in the muscular interstices and meshes of the cellular tissue. The dissemination of these products multiplies their points of contact with the walls of the veins and lymphatics, whence result their imbibition and diffusion into the general circulation."
But, discuss any therapeutical agent as we may, there is something still peculiar to each that evades expression by tongue or pen. Of what use is it to describe odors, tastes, sensations, sights, and sounds? They can only be comprehended by smelling, tasting, feeling, seeing, and hearing. Just so with the peculiar calm, soothing, restful, light feeling that so often results from massage, which can not be understood until experienced. It doubtless arises to a great extent from the pressure of natural worn-out débris being speedily removed from off terminal nerve-filaments. Furthermore, massage excites and awakens the muscular sense in an agreeable and beneficial manner such as nothing else does, and we know that the state of our muscles indicates and often determines our feeling of health and vigor, or of weariness and feebleness. To many minds a more satisfactory way of explaining the phenomena produced by massage would be by saying that they all occur in consequence of "magnetism," by which they have an indefinite understanding that this is some sort of imperceptible, ethereal fluid passing from one person to another. Such an explanation is low, gross, and vulgar, and it is erroneously used as a synonym for personal influence by people who do not know the proper scientific meaning of magnetism. Those who claim to have a vast stock of "magnetism" are like those who talk much of their bravery—sensible people find them devoid of either.