The Art of Massage J. H. Kellogg, M.D. 1895   MASSAGE OF SPECIAL REGIONS.  
 
    In the foregoing pages has been given a careful description of the various procedures employed in massage. I will now proceed to give more specific directions for the general and local application of. massage in which the various manipulations are combined.

377
    General Massage. - The order of application to different parts of the body in the administration of general massage should be as follows:

    (1) Arms ; (2) chest ; (3) Legs; (4) Abdomen ; (5) Hips; (6) Back; (7) Head.
    In the application of the different procedures named below, it should be understood in general that the parts are to be gone over with each manipulation from four to eight times. For specific directions respecting the application of each of the various procedures, the reader is referred to previous pages, except in the case of such movements as are especially adapted to particular regions, directions for which will be given as may be required to make their application plain.

378
    Massage of the Arm. - The several procedures are applied in the following order:
    1. Friction - light centripetal (193, 199-201, 213-217).
    2. Fulling (244).
    3. Friction - spiral and centripetal (196).
    4. Petrissage, or muscle kneading (248-254).
    5. Rolling (255-260).
    6. Friction - centripetal.
    7. Wringing (261-264).
    8. Friction - centripetal
    9. Percussion - hacking (316), spatting (314), beating (317).
    10. Joint movements (343-348) - flexion, extension, rotation, stretching, etc. (355-365, 372-376).
    11. Vibration  - shaking (303).
    12. Stroking (175, 169-172).

379
    In masseing the arm, centripetal friction and fulling are first applied to the whole arm, beginning with the hand, as preliminary treatment. Friction and deep kneading are then alternately applied in sections, first to the hand, then the forearm, then the upper arm. Procedures 5, 6, 7, 8, 9, 11, and 12 are applied to the entire arm; joint movements (10) are applied in succession to the fingers, wrist, elbow, and shoulder; rolling, wringing, and stroking, from above downward; friction, from below upward; percussion, both from above downward and below upward. Shaking, or vibration, may be applied simultaneously with stretching.

380
Massage of the Chest. - Order of movements: 
    1. Friction - centripetal (very light) (203, 222).
    2. Fulling (carefully) (244).
    3. Friction.
    4. Palmar kneading (266).
    5. Percussion - tapping (313), hacking (316), spatting (314), beating (317), clapping (for very fleshy persons only)
    6. Assistive and resistive respiratory movements (381-384).

381
    To assist expiration, compress the sides of the chest during expiration, or raise the arms outward and upward with inspiration.

382
    To resist inspiration, place one hand upon the abdomen, causing the patient to lift it upward by the inspiratory movement, making at the same time a degree of pressure adapted to the patient's condition; or a shot-bag may be used instead of the hand (Fig. 72).

383
    To resist expiration, have the patient breathe through a small tube (Fig. 72) or through a small opening in the lips.

384
    In massage of the chest, great care should be observed that the patient breathes properly. The patient should be taught the proper mode of chest and waist expansion in breathing (Fig. 73). Few women know how to expand the lower part of the chest. Patients should be made to inspire through the nose, and to take deep and slow respirations.

385
    Massage of the Leg. - The order of movements is essentially the same as for the arm, as follows:
    1. Friction - centripetal (193, 202).
    2. Fulling (244).
    3. Friction - spiral (196), circular (195), centripetal (219-221).
    4. Petrissage, or muscle kneading (248-254).
    5. Rolling (255-260).
    6. Friction - centripetal.
    7. Wringing (261-264).
    8. Friction.
    9. Percussion - backing (316), spatting (314), beating (317), clapping (315).
    10. Joint movements (343-348) - flexion, extension, abduction, adduction, circumduction, stretching (366-372).
    11. Shaking (303).
    12. Stroking (175, 169-172).

386
    Movements 1 and 2 are preparatory; 3 and 4 are applied successively to the feet, lower leg, and thigh; 5, 6, 7, and 8 are applied in succession to the leg and thigh in connection with 3 and 4 ; 10 is applied successively to the toes, ankle, knee, and thigh; 9, 11, and 12 are applied to the whole leg.

387
    The principles laid down in relation to massage of the arm apply equally to the leg.

388
    The muscular structures of the thigh are so massive in adults, and especially in very fleshy persons, that they cannot be so conveniently grasped as in the arm and lower leg, hence it is impossible to so perfectly individualize muscles and muscular groups in the manipulation. Rolling movements must, to a considerable extent, be substituted for petrissage. Special pains must be taken, however, to follow the general contour of the bones, so as to lift and stretch every muscle, working especially over the course of the great vessels which lie along the inner border of the extensors, and taking care to pull and stretch the muscular masses away from them on each side.

389
Massage of the Abdomen. - Order of movements:
    1. Preliminary movements - deep breathing (441,461); inspiratory lifting (444, 445); lifting the abdominal contents (442).
    2. Reflex stroking (395).
    3. Nerve compression (160, 396, 397).
    4. Vibration - deep vibration, lateral shaking, circular shaking (398-400).
    5. Percussion - tapping (313), spatting (314), hacking (316), beating (317), clapping (315).
    6. Deep kneading - digital kneading of the colon (404, 405); kneading of the colon with the fist (406-408); kneading of the colon with the fingers and heel of the hand (412-414) ; kneading of the colon with the thumbs (409, 410).
    7. Mass kneading of the abdominal contents (411).
    8. Rolling (415).
    9. Fulling (carefully) (420).
    10. Petrissage, or muscle kneading (421, 422).
    11. Stroking (175, 170).
    12. Percussion of lumbar spine and sacrum (315-317).
    13.. Hips-raising and knees-separating exercises (481, 482).
    The twelfth step may be omitted when massage of the abdomen is employed in connection with general massage, as it is included in massage of the back (426), and also the knees-separating exercise (13), which is included in joint movements of the legs (385 (10), 366-371).

390
    The following rules should be carefully observed in abdominal massage:
    1. General abdominal massage should not be administered until two hours after eating.
    2. The bladder, should always be emptied just before abdominal massage.
    3. In obstinate cases of faecal accumulation, a coloclyster ( large enema taken in right Sims's, or knee-chest, position ) of warm water should be administered, the water being allowed to pass off before treatment.
    4. The patient should be taught to relax the abdominal muscles, and to breathe deeply and regularly during treatment.
    5. If the abdomen is very sensitive, apply a hot fomentation before giving the massage.
    6. If the skin perspires very freely, render it firm and smooth by sponging with cold water.
    7. Very "ticklish" patients require careful education by avoidance at first of superficial movements.
    8. Pain and coldness of the extremities, or depression, after abdominal massage, is due either to bungling or violent treatment, or to extreme hyperaesthesia of the abdominal sympathetic. In such cases, employ fomentations and the moist abdominal bandage in connection with massage.
    9. It is important in all manipulations of the abdomen to exercise great care not to excite pain. All movements should be executed in such a manner as to avoid sudden thrusts, thereby causing the patient pain or other disagreeable sensations, as such disturbances create rigidity of the abdominal muscles, thus seriously interfering with the effects of the manipulations.
    10. In applying massage to the abdomen, the operator should stand over the patient, so as to aid his hands, as far as possible, by the weight of his body, taking care, of course, to graduate the pressure to the requirements of each individual case.
    11. All deep-kneading movements in massage of the abdomen should be slower than for other parts of the body, to allow time for movement of the faecal mass.

391
    Therapeutic Applications. - Abdominal massage is so important a therapeutic procedure, and is so much employed as a special measure of treatment, that the subject is worthy of further consideration and, a more particular description of the several procedures enumerated, and of the conditions in which each is useful.  Abdominal massage is useful for the following purposes:
    1. To relieve chronic constipation.
    2. To aid stomach, intestinal, and liver digestion.
    3. To promote the absorption of fluids and elimination by the kidneys in ascites and in cases of deficient renal action.
    4. For the removal of abnormal deposits of fat.
    5. To develop weak or relaxed muscles.
    6. For the replacement of displaced viscera in enteroptosis. The stomach, general intestinal mass, colon, one or both kidneys, spleen, and liver when prolapsed may usually be replaced by proper manipulations.
    7. Abdominal massage is a necessary accessory in the treatment of many forms of pelvic disease.  Indeed, in most of these cases the primary seat of the disorder is the abdomen rather than the pelvis.

392
    The most common and important use of abdominal massage is as a means of relieving chronic intestinal inactivity. The general causes of constipation, as regards conditions of the bowels which may be relieved by massage, are the following:
    1. Relaxed abdominal muscles, resulting in prolapse of the bowels and other viscera, and consequent stasis of the intestinal contents, with resulting dilatation of the colon. The dilatation may exist either in the caecum or the sigmoid flexure, or the entire colon may be affected. In consequence of delay to evacuate the bowels, the faecal contents often form hard masses, as the result of the excessive absorption of fluid due to their .prolonged sojourn in the colon.
    2. Deficient production of bile, due to an inactive state of the liver, either as a result of inactivity in the portal circulation, or that, condition of the liver termed by the French "hepatism," in which there is some local functional derangement. This condition, commonly spoken of in this country as "torpidity" or "biliousness," is one in which the liver fails to perform its work effectively in destroying ptomaines which are received in the food or are formed in the alimentary canal, or to convert into less toxic forms the leucomaines, or tissue poisons, normally developed in the system and prepared by the liver for elimination by the kidneys. This condition is commonly present in rheumatism, gout, and the various conditions included under the term "uric acid diathesis".
    3. Deficient activity in the nerve elements supplying the intestines and controlling the reflexes by which peristalsis is maintained, the contents of the bowels moved along the intestine, and the normal diurnal rhythm maintained whereby the residuum reaching the lower part of the colon is regularly discharged from the body.

393
    The immediate indications in relation to the removal of these causes, so far as massage is effective to accomplish it, may be enumerated as follows :
    1. Increase of glandular activity by an increase of the activity of the blood current in the portal vein, and stimulation of the abdominal sympathetic ganglia, the splanchnics, and Meissner's and Auerbach's plexuses, the nerve mechanisms which control the motor, vascular, and secretory functions of the intestines.
    2. Increase of peristaltic activity through a stimulation of the nervous reflexes by which this activity is maintained, and by an increased outflow of bile from the liver, the natural laxative by which rhythmical peristaltic activity is promoted.
    3. Relief of passive congestion of the portal system and of the viscera under the influence of this branch of the circulatory system, especially the liver, spleen, stomach, and intestines, thus aiding the return of these structures to a normal state and a consequent restoration of their functions.
    4. Mechanical dislodgment of the contents of the colon.
    5. Development of the abdominal muscles, thereby increasing intra_abdominal tension, which favors expulsion of the intestinal contents.
    6. Replacement of displaced viscera.
    Not infrequently - in the majority of cases, in fact - all of, these indications are found coincidently present.
    The procedures offered by massage by which these indications are best met, are the following :

394
    1. To stimulate the nervous reflexes, and hence the peristaltic, glandular, and vascular activities, under control of the abdominal sympathetic.

395
    This may be accomplished by employing the following measures:-
    (1) Reflex Stroking. - With the ends of the fingers, make very light strokes in a circular or semicircular direction about the umbilicus. Begin very close to that point, gradually extending outward, then return and repeat. Also make vertical strokes along the sides in the mammary line, and parallel with the rectus muscle. Strokes may also be made over the fourth, fifth, and sixth ribs at the sides of the chest. In sensitive persons, one-sided contraction of the abdominal muscles or a twitching at the epigastrium will be noticed as the result of the so-called abdominal and epigastric reflexes. This procedure is strongly exciting ; some patients are not able to endure it. The profound reflex effect produced in patients who are very sensitive, or "ticklish," is evidence of the strong influence of this procedure upon reflex nervous activity.

396
    (2) Nerve Compression (Figs. 35, 76). - The stomach and the intestines are directly controlled by the solar plexus and the lumbar ganglia of the sympathetic. The solar plexus is at the epigastrium, just below the lower end of the sternum. The chief lumbar ganglia are situated on each side of the umbilicus, about two inches from it. Pressure upon these ganglia has a marked stimulating effect, because they send out energetic nerve impulses into the parts which they supply, which include not only the stomach and the intestines but all the abdominal viscera.
    It should be remembered that these nerve masses lie beneath the abdominal contents, resting upon the bodies of the vertebrae. It is hence necessary to make a considerable degree of pressure in order to reach them. The tips of the fingers, being placed upon the points indicated, should be carried directly back toward the spinal column, the patient in the meantime being directed to take first a full breath and then to exhale as completely as possible. This diverts the mind of the patient from the procedure which is being executed, and also diminishes the abdominal tension, thus making it less difficult to bring pressure to bear upon the posterior wall of the abdominal cavity.
    With patients who are extremely fleshy, and in cases in which the abdomen is greatly distended with gas, this procedure can be executed only in a very imperfect manner.

397
    The position of the patient is a matter of great importance. The shoulders should be slightly raised and the knees well drawn up, the legs being supported, so that the anterior abdominal wall shall be relaxed as much as possible. The patient's hands should be by his side, and all the muscles of the body in a state of rest. Only gentle pressure should be employed, and the application should be continued only two or three seconds at each point. In many cases it will be found that extreme sensitiveness exists at the points indicated, which is evidence of an excited or hyperaesthetic state of the abdominal sympathetic. Continuous gentle pressure may be beneficial, even in these cases, however, acting as in other cases of abnormal nerve sensibility, as chronic sciatica, by setting up a series of vital activities which result in the restoration of the nerve to its normal condition.

398
    (3) Vibration. - (a) Strong vibration applied to the abdominal contents has been shown to be one of the most powerful means of stimulating the nervous reflexes, circulation, glandular activity, and peristalsis, which can be employed for this part of the body. Either one or both hands may be used. The flat palm of the hand is applied to the surface, with the arm extended, and fine vibratory movements are executed in such a manner as to throw the whole abdominal contents into vibration. The same movement, which consists of a sort of trembling, as elsewhere described, may be beneficially applied to the liver (Fig. 55).

399
    (b) A more vigorous shaking movement is communicated to the abdominal contents by making intermittent pressure either with one hand, or with one hand reinforced by the other, or by both hands in alternation, the movements being made with sufficient rapidity to produce a decided motion of the abdominal contents. The effect of this procedure is very marked in cases in which the abdominal walls are considerably relaxed.

400
    (c) A third method of applying shaking is by placing the palm of the hand upon the abdomen, the arm slightly flexed, then making a rapid rotary movement without allowing the hands to slide upon the surface. The direction of the movements is alternated, half a dozen in one direction and then an equal number in the opposite direction.

401
    (4) Percussion . - This is unquestionably the most powerful of all the stimulating means which can be applied to the viscera through the abdominal wall. All the different modes of percussion, viz., tapping, spatting, clapping, hacking, and beating, may be usefully employed. The mode of executing these movements has been elsewhere indicated.

402
    2. To produce mechanical effects by means of which stasis of the intestinal contents may be overcome and accumulated faecal matter dislodged at the same time that the circulatory and g1andular activities are stimulated.

403
    For this purpose deep kneading is especially to be, recommended. This may be accomplished by a number of different procedures :

404
    (1) Digital Kneading (Fig. 77). - Standing face to the patient's feet, and with the fingers very slightly flexed, place the finger tips, the hand being reinforced by the other hand placed above it, upon the abdomen, low down upon the right side. Crowd the finger ends backward, pressing with as much force as possible without giving the patient much inconvenience, against the caecum. Carry the hand upward in the direction of the ascending colon as far as permitted by the ribs. Repeat the movement four or five times. Execute similar movements on the left side, beginning above instead of below, pressing the fingers upon the abdominal wall at a point close under the ribs on the left side. Carry the hand downward, turning toward the median line at the conclusion of the movement, so as to follow as closely as possible the course of the sigmoid flexure of the colon.

405
    In cases in which it is believed that a considerable amount of faecal matter exists in the colon, the procedure should be somewhat different. It should begin with the left instead of the right side, and instead of placing the hand at the start close under the ribs, it should be pressed down at a point two or three inches above the point at which the movement terminates. After two or three movements starting at this point, the hands should be carried a little farther upward, the strokes repeated as before, and the hand carried at each stroke down to the lowermost point which can be reached.
    After doing the left side in this manner, execute the same movements upon the right side, beginning at a point just below the ribs instead of at the lower end of the caecum, and gradually increasing the length of the stroke from below upward until the lower end of the caecum is reached. The above movements may be advantageously repeated with the patient lying in the right. or left Sims position, the left side for the ascending colon, and the right side for the descending colon.

406
    (2) Kneading with the Closed Fist (Fig. 78). - With the closed fists used in alternation, work along the whole course of the colon, beginning at the lower end of the caecum, directing the movements upward to the lower border of the ribs on the right side, following the oblique border of the ribs to a point midway between the umbilicus and the sternum, at which the median line is crossed ; then down on the opposite side, ending at a point close to the pubic bone, and just to the left of the median line.
    It should be remembered that the colon lies much deeper at the sigmoid flexure than at any other portion of its course, so that in order to reach the lower part of the colon it is necessary to press the hand in as deep as possible without giving the patient too much inconvenience. The movements must be directed with great care and deliberation.

407
    The rate of movement should not be more than thirty per minute, or two seconds for each hand. Care should be taken not to release the pressure upon the bowels with one hand until the other hand has been placed in position just in advance and close to it. Care must also be taken to follow the curves of the colon.

408
    In the directions given above, the colon is supposed to be in normal position. This is by no means always the case, however. In the majority of women who have worn the ordinary dress, and in nearly all elderly women, the colon will be found more or less prolapsed. The prolapse usually involves chiefly the central portion of the colon, as this portion is more easily displaced than the points of junction of the ascending and descending colon with the transverse portion. The case shown in Fig. 95, a photograph of which was sent to the writer by Professor Meinert, of Dresden, Germany, will give a good idea of the unnatural conditions often found in these cases. Many cases equally bad have been encountered by the writer. A fairly correct idea of the location of the colon may be obtained by noticing the contour of the abdomen when the patient is placed in a sitting or standing position. The colon may be considered as lying along the line of greatest prominence. This may be observed with the patient standing or sitting, and marked with a soft sketching pencil or a bit of cotton moistened with tincture of iodine.

409
    Kneading with the Thumbs (Fig. 79). - With the fingers behind and the thumbs in front, grasp the loin on each side between the thumb and the fingers. The right hand should thus grasp the lower end of the caecum, while the left hand grasps the upper part of the descending colon just beneath the ribs. Movements are then executed in an upward direction with the right hand, and a downward direction with the left hand, the operator facing the patient's feet.

410
    In thin persons the ascending and the descending colon can be more efficiently manipulated in this way than in almost any other, as at least some portion of the intestine may by this procedure be actually seized between the fingers and the thumb, and the contents forced along. When the colon is loaded with faecal matter, thumb kneading, as well as fist and palmar kneading, should begin near the ribs on the right side, and as low down as possible on the left side, working gradually downward and upward respectively, in such a manner as to clear the way.

411
    (4) Mass Kneading (Fig. 80). - Still another procedure which is of value in abdominal massage, is what may be termed "mass kneading," in which the operator endeavors to seize the abdominal contents with both hands, manipulating them precisely as a baker does a mass of dough, the fingers of one hand being used in opposition to the heel of the other hand, and the abdominal contents kneaded and manipulated between the two hands. In this procedure the heel of one hand of the manipulator operates upon the side of the patient near est him, while the fingers of the other hand operate upon the tissues of the opposite side. Mass kneading is only applicable to cases in which the abdominal walls are considerably relaxed.

412
    (5) Palmar Kneading. _ Two movements, both of great value, may be executed with the heel of the hand, as follows:

4l3
    (a) Describe a circle about the umbilicus, the hands being used in alternation, the heel of one hand moving up on the right side, and the other moving down on the left side, the stroke on the left side being made to slightly overlap that of the right side. This acts especially upon the small intestines.

414
    (b) Starting at the lower end of the ascending colon, work the whole colon with the heel of the hand, carefully following its direction from the caecum to the sigmoid flexure, one hand assisting the other by supporting the tissues to prevent overstretching the skin. Or, knead the ascending colon with the heel of the hand, the transverse colon with the ulnar side of the hand, and the descending colon with the tips of the fingers. This method obviates the necessity of changing the position of the body during manipulation.

415
    (6) Rolling. - When the abdominal walls are considerably relaxed, they may be gathered between the hands placed parallel with the body, one on each side, and thus compressed, rolled, and shaken, together with the intestinal contents. Care must be taken to include the abdominal contents_ not simply the skin and subcutaneous tissue or a mass of subcutaneous fat. The patient's position must be such as to secure very thorough relaxation of the abdominal muscles in order to make this procedure effective.

416
    (7) Massage of the Gall Bladder. - The movement of the bile from the liver toward the intestine may be assisted, and the liver be gently manipulated, by applying pressure with the left hand as follows: The operator, standing by the left side of the patient, places the left hand at the lowermost border of the ribs of the right side; a stroking movement is then executed along the lower border of the ribs of the right side in the direction of the epigastrium, the fingers being crowded up under the ribs as high as possible or until the lower border of the liver is felt. In this way it is possible to reach the gall bladder, and to facilitate the discharge of its contents into the intestine. The bile being a natural laxative, this is one of the most effective means of stimulating peristaltic activity.

417
    Care should be taken to place the patient in such a position as to completely relax the abdominal muscles, and he must be made to take long, deep inspirations during the procedure, so as to prevent, so far as possible, spasm of the abdominal muscles.

418
    3. To Strengthen the Abdominal Muscles
    Massage alone is not sufficient as a means of developing the abdominal muscles, as is the case with all muscular structures. They must be brought into voluntary action by proper gymnastics, for which the Swedish gymnastics and the manual Swedish movements, or medical gymnastics, afford the most effective means. The application of electricity, particularly of the sinusoidal current, is the most efficient of all modes of passive exercise. This current, used with slow alternations, brings the muscles of the abdomen into vigorous contraction without producing pain or other sensation than that of motion. Much, however, can be accomplished by massage. The following procedures are the most effective :

419
    (1) Kneading. - As with other muscular structures, kneading is the most effective of the procedures afforded by massage, for stimulating development of the abdominal muscles. Both superficial kneading, or fulling (244), and deep kneading, or petrissage (248-254), may be employed.

420
    (a) Apply fulling movements to the whole abdominal surface, working up and down in the direction of the recti muscles, and in circles about the umbilicus.

421
    (b) In deep kneading, or petrissage, of the abdominal muscles, care should be taken, as in other regions, to include the individual muscles or groups of muscles in the grasp of the hand, as far as possible. The recti and the external oblique are the only muscles readily accessible to the hand. The outline of these muscles may be easily discerned by causing the patient to raise the head by forcible effort, and without the assistance of the arms. Forcible contraction of the recti muscles causes the external oblique to bulge at the sides, showing the outline of both sets of muscles. When the abdominal muscles are thoroughly relaxed by proper position, and in cases in which they are especially in need of this form of treatment, the recti muscles can be quite easily grasped and manipulated individually. The external oblique is less easily managed, but by a painstaking effort the whole muscle can be subjected to a thorough manipulation.

422
    A very effective mode of masseing the recti muscles is to cause the patient to raise the head (Fig. 81); then, with both hands placed upon the abdomen in such a mariner that the thumbs rest upon the recti, the operator facing the patient, the muscles are rapidly manipulated by the thumbs, working from below upward.

423
    In some patients these manipulations are apt to produce excoriations of the skin in consequence of its thinness. This is especially the case when the skin becomes moist by perspiration. To obviate this difficulty, the surface should be well lubricated with cacao butter or talcum powder.

424
    Replacement of the Abdominal Viscera. - This is necessary in many cases of abdominal massage, as a preliminary procedure. It is especially required in women, since in the majority of invalid women some of the viscera are almost certain to be found displaced. The stomach is displaced from two to five inches below its normal position in nineteen out of twenty of all adult civilized women who have worn the conventional dress. A movable, or floating,.right kidney is to be found in at least twenty-five per cent of women who are likely to require abdominal massage. The liver is also not infrequently found displaced. The methods employed in replacing the various viscera are given elsewhere (439-450).

425
    Massage of the Hips. - With the patient lying upon the back the manipulations are applied to the fleshy portions of the hips, or the buttocks, the several procedures being administered in the following order:
    1. Light centripetal friction (193).
    2. Fulling (244).
    3. Circular friction (195, 203).
    4. Petrissage (248).
    5. Palmar kneading (266).
    6. Centripetal friction.
    7. Nerve compression along the sacroiliac synchondrosis (junction of sacrum with iliac bones) and over the sciatic nerve (Fig. 35).
    8. Percussion-hacking (316), spatting (314), beating (317), clapping (315).
    9. Stroking (175).

426
    Massage of the Back. - The patient lies upon the face, the forehead resting upon the crossed hands, the elbows well raised from the sides so as to spread the scapulae and uncover as much of the back as possible:
    1. Centripetal friction (193).
    2. Fulling of the neck, shoulders, sides, and loins (244).
    3. Friction - circular (195), centripetal (193).
    4. Deep kneading - palmar kneading, or rolling, above the scapulae (Fig. 53); digital kneading, following the ribs (292); palm kneading up and down the spine (288, 291, 494); digital kneading of the spine (Fig. 54) (287, 289, 290, 293).
    5. Nerve compression (156); spine stretching (427).
    6. Percussion of spine and sacrum - tapping, hacking, slapping, beating, clapping (313-317)
    7. Friction (alternating with kneading, as above) (228).
    8. Stroking (175, 176).

427
    Spine stretching may be applied in one of the following ways:
    1. Suspension by the head or the head and shoulders. By means of an improved form of apparatus which the writer has had constructed, and has used for several years, the tension upon the head and shoulders may be separately determined and proportioned with accuracy.
    2. The patient lying upon his face, hips and chest supported by pillows, his head is strongly flexed by the masseur over the end of the couch.
    3. The patient sitting with legs extended horizontally, leans forward while the attendant flexes his head strongly forward.

428
    Massage of the back is a very agreeable procedure for most patients. The skin of the back is but little sensitive, and will bear the employment of considerable force. Percussion of the spine is one of the most powerful means of affecting the deep_lying nerve centers, and affects not only the spinal centers but, reflexly, the sympathetic centers also, and through the splanchnics, influences the circulation in the stomach and intestines. Pain in the spine is most often due to hyperaesthesia of the abdominal sympathetic but is often due to anaemia which may be present, or the result of spasm of the vasomotor centers, having its origin in sympathetic irritation. The pain usually disappears under treatment when the force employed is graduated with sufficient care. Fomentations applied daily and the moist, or so-called heating, compress worn at night are necessary adjuncts to massage in cases in which there is much tenderness of the sympathetic. Pain in the sacral region may be due to rectal, ovarian, or bladder disease. Pain in the lumbar region is usually due to hyperaesthesia of the abdominal sympathetic. Pain in the dorsal region originates in irritation of the solar plexus.

429
    Massage of the Head. - Massage of the head and neck is not usually included in general massage, but may often be advantageously added to the general manipulations as a means of quieting any slight excitement which may have been produced, and leaving the patient in a restful state. Head massage is especially valuable for the relief of headache, neurasthenic pains, baldness, the dullness and other uncomfortable sensations resulting from loss of sleep, cerebral anaemia, neuralgia, and migraine.

430
    The procedures which I have found most useful are the following, usually employed in the order given :
    1. Digital kneading, from forehead to occiput (Fig. 83) (268).
    2. Hacking (316), from before backward.
    3. Chucking (Fig. 45), one hand placed upon the forehead or the side of the head, the other opposite.
    4. Tapping (313).
    5. Hacking.
    6. Head rolling, flexion, and twisting both active and passive, repeated four to eight times.
    7. Stroking from vertex to base of skull, down back of neck, and along the submaxillary groove.
    8. Vibration - shaking (303).
    9. Pressure.
    10. Hypnotic stroking (189).

431
    In cases of great immobility of the scalp (a "hidebound" condition), when necessary, a better hold of the scalp may be obtained by grasping the hair between the fingers close to the roots. Care should be taken, however, not to give so great latitude to the movements as to produce unpleasant sensations from pulling the hair.

432
    Neck Massage. - The purpose of neck massage is to withdraw blood from the brain. The circulation in the brain is so directly affected by the breathing movements that it is especially important that respiration should receive attention. The patient should sit with the head well raised, the arms extended downward as far as possible, so as to expose the neck to the fullest extent, and should be made to execute deep breathing movements for a few times before the manipulations are begun, so as to insure full respiration, and to distract his attention from the manipulations. The strokes should be made at the same time with inspiration, and with both hands simultaneously, except in cases in which the throat is so sensitive that irritation of the larynx and coughing result from compression of the larynx between the fingers or thumbs of the two hands, when the strokes should be made in alternation.

433
    Höffinger's Method. - Massage of the neck may be applied in several ways. The following is known as Höffinger's Method (Fig. 84): The patient sits upon a high seat, the operator standing behind. The hands are brought in contact with the neck in such a way that the little fingers fall into the groove beneath the jaw. The hands are then made to move downward, the arms rotating inward at the same time, the ends of the fingers pressing upon the jugular veins. After a few strokes over the anterior portion of the neck, similar strokes are made with the thumbs over the back part of the neck. The deep breathing should be continued during the manipulation.

434
    Höffinger employs only manipulations of the anterior portion and sides of the neck. Experience has led me to employ also manipulation of the back part of the neck, extending from the occiput down on either side of the ligamentum nuchae to the vertebra prominens. This manipulation powerfully influences the cervical sympathetic, and is of very great value in cases of occipital headache and the "neckache " so common with neurasthenics.

435
    Gerster's Method. - Massage of the neck may also be applied from the front - Gerster's method (Fig. 85). With the fingers extended and held close together, the palm upward, the little fingers are applied to the neck just below the ears. The hands are then moved downward and rotated inward, so that the tips of the thumbs fall on each side of the larynx. Friction is thus applied in such a manner that the fingers compress and empty the external veins, while the thumbs press upon the internal jugular veins.

436
    In the case of children or persons with very small necks, the thumb may manipulate the front part of the neck while the fingers are applied to the back of it (Fig. 86).

437
    Author's Method. - I employ hacking and fulling, as well as friction, and direct my manipulators to apply the following procedures in the order given :
    1. Gentle fulling of the skin of the neck (244).
    2. Friction of the anterior portion of the neck (433 or 435).
    3. Friction of the back of the neck (434).
    4. Percussion - gentle tapping (313) and hacking (316) of the back of the neck from occiput to vertebra prominens. .
    5. Stroking from the forehead backward and down the back of the neck, and from the vertex downward and over the anterior portion of the neck

438
    Neck massage is. an extremely useful procedure for the relief of insomnia and cerebral congestion, and is often effective in cases of migraine and other forms of headache. Some cases have been reported in which non-cystic enlargement of the thyroid gland has been improved by neck massage.

439
    Replacement of the Abdominal Viscera. - Glenard of France, first called attention to the great mischief arising from the condition which he terms enteroptosis, or prolapse of the viscera of the abdomen. A careful study of the subject for the last ten years has convinced the writer that displacements of the stomach, colon, kidneys, spleen, and liver are responsible for a much greater number of symptoms than. is generally supposed, and is the real cause of suffering in a large proportion of cases, especially in women, which have been treated with little or no benefit for supposed disorders of the pelvis. The accompanying cuts (Figs. [1] to [11]) illustrate a few of the many cases of visceral prolapse which have come under the writer's observation within the last ten years. Fig. [1] represents a case in which the right kidney had become so diseased in consequence of its prolapsed condition that its removal by a surgical operation was necessary. In operating, for its removal, it was found to contain a calculus weighing more than four ounces. This was a case in which massage would have been unavailing; but it would have been a measure of great value, had it been employed a few years earlier.
    Figs. 87 to 95 illustrate the causes of visceral prolapse, and will suggest the means necessary to aid recovery in these cases, and the advantages which may be derived from massage. Gastric neurasthenia certainly owes many of its distressing symptoms to disturbance of the abdominal sympathetic resulting from displacements of the sort referred to. I have found,.the following the most effective means of replacing the abdominal contents, as a whole, and restoring the viscera to their normal position:

440
    The patient lies upon the couch with the head, not the shoulders, elevated, and with the knees well drawn up so that the abdominal wall shall be as thoroughly relaxed as possible.

441
    First of all, the patient is made to take several deep breaths, care being taken to see that the abdomen is expanded well with each inspiration (Fig. 73). In women the reverse is likely to be the case.

442
    The next proceeding is to lift the entire intestinal mass as follows (Fig. 75): The masseur stands with his right side to the patient, facing the patient's feet, and places his hands one in either groin, the hands resting upon their ulnar borders (little fingers), and having the direction of Poupart's ligament. The hands are made to move slowly upward, the ulnar borders being at the same time crowded as deep as may be into the pelvis so as to grasp as much as possible of the abdominal contents, which are then drawn forcibly upward.

443
    Shaking and rolling movements are valuable as a preliminary measure, or used in alternation with the lifting movements, as a means of loosening up, so to speak, the abdominal contents, to prepare them for gliding easily into their normal positions. The lifting movements should be executed in alternation with rolling or shaking movements, from three to six times.

444
    Inspiratory Lifting (Fig. 74). - I was led to adopt this means of lifting the abdominal contents by a series of studies for the purpose of noting the influence of respiration upon intra-pelvic pressures. I observed that the ascent and descent of the uterus in respiration may be greatly increased by modifying the inspiratory and expiratory movements. For example by, directing the patient to take a deep breath and then asking her to force the breath downward, it was noticed that the pelvic contents were forced downward to a notable extent; while by causing the patient to completely empty the lungs, and then, with the glottis closed, to make a forcible inspiratory effort, the pelvic and abdominal contents were made to ascend, in a very remarkable manner. In one instance it was noted that the uterus, which lay quite low in the pelvis, was drawn up more than an inch with each respiratory effort.

445
    Inspiratory lifting is administered thus: The patient lying upon the back, with the hands at the side, so as to relax the abdominal muscles as much as possible, she is directed to take first a full breath, breathing as deeply as possible, then to completely empty the lungs. Then, instead of drawing in the breath as usual, the glottis is closed, and a strong inspiratory effort is made without the admission of air. By this method the whole inspiratory force is used in lifting the abdominal contents. In this movement the patient should be made to expand the chest, both the upper and the lower parts, as much as possible, as it is desired to suppress the action of the diaphragm so far as can be done voluntarily, while bringing into most active play those muscles of inspiration which act upon the ribs. This not only produces a powerful upward draft upon the abdominal contents, but at the same time enlarges the waist, and makes room for the viscera, so that their ascent is facilitated.
    At the same time that the patient executes inspiratory lifting (444,445), the abdominal contents should be lifted from below with the hands, as directed above. The patient should not be allowed to refrain from breathing more than ten or fifteen seconds. During this time, however, from three to five vigorous inspiratory liftings may be made. Then the patient may be allowed to take a few ordinary respirations, and finally a deep inspiration, followed by a complete expiration and a renewal of the inspiratory lifting. Repeat with the patient in the knee-chest position. This procedure is of special value in connection with pelvic massage.

446
    Replacement of the Stomach (Fig. 96). - To accomplish this, lifting of the abdominal contents (442) is first executed; then the operator, standing upon the right side of the patient and facing the side, places his right hand upon the left side of the abdomen in such a way that its ulnar border is in contact with the skin and lies in a transverse direction. With the fingers slightly flexed, the hand is first pressed backward, then carried upward and toward the median line in such a way that the tips of the fingers will sweep along the inferior borders of the false ribs, the movement ending at the epigastrium. The hand should be held at this point while the patient is asked to execute a deep breath; the procedure is then repeated.

447
    Replacement of the Right Kidney (Fig. 97). - Displacement of the kidney is always associated with displacement of the stomach and bowels, hence lifting movements (442) and movements for the replacement of the stomach (446) should be employed in connection with those for the replacement of the kidneys.

448
    To replace the kidney, after making movements to replace the stomach and bowels, the operator proceeds as follows: Standing upon the right side of the patient, the fingers of the left hand are placed behind, while those of the right are placed upon the abdomen; and by movements of the two hands the location of the kidneys is determined. While gently pressing the kidney upward, the patient is asked to take repeated deep breaths. With each exhalation, an effort is made to press the kidney up under the ribs of the right side by gentle pressure. As it moves upward and approaches its position, the right hand is shut, and the closed fist is made to follow the kidney and hold it in position while the patient makes a number of deep respirations.

449
    Replacement of the Left Kidney and Spleen. - The method employed is precisely the same as that for the replacement of the right kidney, except that the operator stands upon the patient's left side, and places the fingers of the right hand behind, manipulating the displaced organs with the left hand.

450
    In all cases of enteroptosis, a proper abdominal bandage must be applied after replacement of the prolapsed viscera, and means must be employed for strengthening the abdominal muscles, - gymnastics, massage, and proper applications of electricity, especially the sinusoidal current.

451
Massage of the Stomach (Fig. 96). - This is one of the most important applications of massage. Its objects are:
    1. To aid digestion by stimulating motor activity.
    2. To aid digestion by increasing glandular activity.
    3. To empty the stomach mechanically.
    4. To restore the prolapsed stomach to its normal position.

452
    The most important procedures to be employed are:
    1. Abdominal massage (389).
    2. Standing upon the right side, and with the back to the patient, place the right hand upon the left side of the abdomen opposite the umbilicus; with the fingers extended and close together, press the ulnar border of the hand backward, at the same time carrying it upward with a vibratory movement. Following along under the ribs of the left side, continue the movement upward to the epigastrium. At this point, before releasing the tissues, place the tips of the fingers of the left hand so as to support the tissues at the point to which they have been lifted by the movement of the right hand, making firm pressure ; then withdraw the right hand and repeat the movement. Continue for three or four minutes. If it is desired to empty the stomach, carry the strokes across the epigastrium and along under the lower border of the ribs of the right side.
    3. When the object is to aid digestion, combine with these movements deep breathing movements (441) and inspiratory compression, obtained by having the patient take a deep breath and hold it for a few seconds while strongly contracting the abdominal muscles.
    4. In cases of extreme prolapse of the stomach, in which patients suffer from flow of bile into the stomach, replace the abdominal viscera with the patient in the knee-chest position, standing with the back to the patient's head, grasping the abdomen near the pubic bone, and lifting toward the chest.
    Firm compression of the stomach is an efficient means of suppressing vomiting and hiccough.

453
    Massage of the Liver (Fig. 98). - This procedure is of great value in chronic cases of catarrhal jaundice, gallstones, and in numerous cases of so-called torpid liver, and is, in fact, valuable in all cases in which massage is indicated as a means of securing general improvement in nutrition, as in chlorosis, anaemia, emaciation, and impaired digestion. Increased activity of the liver aids digestion, and promotes especially the fat-making processes and blood formation. Massage of the liver is contraindicated in cancer of the liver, in acute attacks of hepatic colic, in cases of acute gastro-duodenitis, and in hepatic abscess.

454
    The method of procedure is the following, the patient's knees being well drawn up and the shoulders slightly raised, so as to completely relax the abdominal muscles:
    1. Deep breathing with arm raising, four to eight times.
    2. Abdominal massage (389). Whatever aids the portal circulation will assist the liver.
    3. Tapping (313) over the entire region of the liver (Fig. 31), best executed with the patient lying on the left side, which renders it possible to reach the liver behind as well as in front.
    4. Fulling (244).
    5. Kneading. Standing at the left side of the patient, place the left hand behind the liver, against the lowermost ribs of the right side, and with the other hand stroke and knead the liver by pressing up underneath the ribs on the right side. When in normal position, the liver lies half an inch above the lower border of the ribs. The direction of the strokes should be from the loin along and beneath the inferior border of the ribs to the epigastrium, and across to the opposite side.
    6. Hacking (316) over the liver.
    7. Spatting (314).
    8. Deep vibration (jarring) (302).
    9. Inspiratory compression. Have the patient take a deep breath, and then contract the abdominal muscles as firmly as possible while holding the breath. Compression with the hands may be made over the region of the liver. at the same time.
    10. Laughing exercise, consisting of the syllable "ha" uttered in an explosive way, and up and down the scale.

455
Massage in Diarrhoea. - Abdominal massage is of very great value in certain cases of chronic diarrhoea. Of these, two very distinct classes are benefitted by massage, each requiring, however, a different mode of application. In cases in which undigested food substances are passed soon after eating, indicating excessive peristalsis, with deficient activity of the digestive fluids, abdominal massage should be applied for half an hour a short time before each meal. In cases in which the diarrhoea is due to intestinal catarrh, resulting from dilatation of the stomach, whereby the food is retained in the stomach for so long a time that fermentation takes place, causing irritation of the intestinal membrane when the fermenting food substances at last find their way out of the stomach, massage of the stomach (451) should be applied soon after eating, or within an hour after each meal.

456
    General massage, especially massage of the shoulders and back, should be combined with abdominal massage in these cases, and massage should be employed at least once daily. Ordinarily, manipulation of the abdomen for ten or fifteen minutes is sufficient when the application is made after meals.

457
    Pelvic Massage. - This form of massage, first introduced by Major Thure Brandt, a Swedish gymnast, in 1874, has been variously modified by different physicians who have taken up its employment since the favorable reports of Brandt, especially Norström, of Stockholm, Jackson, of Chicago, and Bunge, of Berlin. The method of Brandt and Norström consisted chiefly in supporting the uterus with one finger placed in the vagina and behind the cervix, then making intermittent pressure with the other hand placed externally over the fundus, the uterus being compressed between the two hands. Jackson added gentle manipulations of the abdominal walls, and Bunge ex tended the manipulations to the abdomen.

458
    Pelvic massage concerns the following organs:
    1. The uterus.
    2. The uterine appendages - ovaries, Fallopian tubes, broad, round, and other ligaments.
    3. The vagina, in cases of rectocele and cystocele.
    4. The rectum, in cases of prolapsed and relaxed rectum.
    5. The prostate in men; sometimes, also, the bladder, in cases in which it is atonic.
    6. The coccyx, in cases of coccygodynia, in both sexes.

459
    Pelvic massage should never be undertaken by any person who is not a qualified and experienced physician. The success of this procedure depends, first, upon a correct diagnosis; and secondly, upon special aptitude on the part of the masseur.

460
    It is scarcely possible for a person to become proficient in this special application of massage without personal instruction from some one who has by long experience become skilled in its employment and in the selection of cases to which it is adapted.
    It is hoped, however, that the student may obtain an intelligent idea of pelvic massage by the following description of the method which some twelve years' experience has led the writer to adopt:
    Position. - The patient lies upon the back, with the heels well drawn up, the knees separated, the hips slightly elevated, arms by the side, and the head (not the shoulders) supported by a thin pillow.
    1. Preliminary movements (461-467).
    2. Intermittent compression of the uterus (468-470).
    3. Digital kneading of the uterus (471).
    4. Lifting movements (472,473).
    5. Vibration of the uterus (474).
    6. Kneading of the appendages (475).
    7. Digital kneading of the round ligaments (476).
    S. Stretching of adhesions and kneading of exudates (477).
    9. Nerve compression (478).
    10. Massage of the abdominal muscles (480).
    11. Finishing movements (481-483).

461
    1. Preliminary Procedures. - The manipulations practiced in pelvic massage are rendered very much more efficient by the application of a few preliminary movements for the purpose of placing the abdominal and pelvic contents in the most favorable condition possible in any given case. It should be remembered that in pelvic displacement there will always be found, also, displacement of the abdominal contents. When the uterus falls backward, the folds of intestines which have formerly been behind it, aiding and supporting it in its position, change their position, overlying it above and in front. Replacement of the uterus requires, first of all, a replacement of the intestines; in other words, room must be made for it in its old position before it can be restored to its normal place.

462
    It should also be borne in mind that in most cases, displacement of the pelvic viscera is accompanied by a serious disturbance in the positions of the various abdominal organs. There will be found in nearly every case of this sort, displacement of the colon and stomach, and not infrequently displacement of one or both kidneys, and occasionally downward displacement of the liver. It is consequently evident that pelvic massage should always be preceded by such manipulations as will, so far as possible, aid in the restoration of the abdominal viscera to a normal position and condition.

463
    The preliminary movements which I, have found most effective, are : (1) Deep breathing; (2) Lifting abdominal contents ; (3) Inspiratory lifting.

464
    (1) Breathing Movements. - The patient is made to execute a few full breaths (Fig. 73), in which the lower part of the chest and the abdomen are well expanded with inspiration, and drawn in as far as possible with expiration.

465
    (2) Lifting the Viscera. - After the patient has taken three or four deep breaths, the physician stands at the patient's left, and, with his back to the patient, places the ulnar edge of the two hands, with the fingers extended, just over Poupart's ligament, and parallel with the ligament, the fingers pointing toward the pubes. From this position the hands are moved slightly upward, the edge of the hands being made to sink as deep into the abdomen as possible without severe pain, the arms being slightly rotated at the same time, and the hands drawn upward in such a way as to grasp the contents of the abdomen and drag them upward. This movement is repeatedly executed during the act of inspiration, the patient continuing to take deep and full breaths, expanding the lower chest and abdomen as previously described. See that all displaced viscera are in perfect position.

466
    Essentially the same movement may be executed with the patient in the knee-chest position. The masseur stands with his back to the patient's head, and reaching around the patient with one arm, drags the bowels upward during inspiration.

467
    (3) Inspiritory Lifting (Fig. 74). - A number of years ago, when engaged in a series of experimental studies of intra_ abdominal pressure, and while one day administering pelvic massage to a patient in whom the uterine supports were greatly relaxed, I observed that with each forcible inhalation the uterus was lifted upward a distance of half an inch or more. I noticed also that the patient was breathing almost wholly with the upper chest. In order to intensify the effect of the inspiratory lifting, I caused the patient to exhale completely, and then to make the movement of inspiration by lifting the upper chest forcibly while keeping the glottis closed, so that the air could not enter the lungs. The effect of this procedure was very remarkable, the uterus being lifted in an upward direction more than an inch.

468
    2. Intermittent Compression of the Uterus . - The preliminary movements being completed, one, or, when possible, two, fingers (index and middle fingers) of the left hand are introduced into the vagina and crowded upward behind the cervix, the uterus being first placed in perfect position, then lifted upward and forward as far as possible without giving too much pain. The extended fingers of the right hand are at the same time pressed upon the abdominal wall just above the pubes, so as to impinge upon the fundus, covering as large an area of the uterus as possible. Firm, intermittent pressure is then made, continuing for two or three seconds, with intervals of one or two seconds, this being repeated six to twelve times. In this procedure the pressure of the external hand will fall chiefly upon the top of the fundus.
    In many cases it is difficult to tilt the uterus forward, even after the previous lifting of the abdominal contents which has been described. In the effort to restore the uterus to its normal place, much assistance may be obtained from manipulations with the hand employed externally. The extended palm may be used in lifting the abdominal contents, working from the pubes upward ; or the closed fist may be pressed backward just above Poupart's ligament and the pubes, and crowded upward while the patient makes breathing movements. By this means the way may be cleared so that the tips of the fingers can finally be gotten down behind the uterus, even in cases of retroversion.
    Sometimes the cervix must be grasped between the two internal fingers and used as a lever to pry the fundus up, when the organ, has sufficient firmness to admit of such a procedure. It is often necessary to work the fingers of the external hand down upon one side at the same time that the internal fingers are crowded up as high as possible. In this way a fundus lying in the hollow of the sacrum may be slid up over the promontory of the sacrum, when the fingers of the external hand,
working down beneath it, will quickly bring it into position.

469
    When the vaginal orifice is too small to admit of two fingers, a useful application of massage may be made by the aid of one finger introduced into the vagina, or even a single finger operating through the rectum. A single finger, however, has less perfect control of the uterus, and in cases of extreme backward displacement it is often impossible to completely replace the uterus by means of one finger only working internally. A better method, in cases in which the vagina will admit of but one finger, is to introduce the forefinger into the vagina and the middle finger into the rectum. The remaining fingers of the hand should not be flexed, but extended and separated from the middle finger, and slid over the coccyx. A special advantage in the last_named method is that it facilitates palpation of the ovaries and tubes, the movements of the middle finger not being restricted by the vaginal walls.

470
    Without allowing the uterus to drop down in the pelvis, the two fingers of the left hand are now transferred to the front of the cervix, the uterus being supported by the external hand, the fingers of which are made to pass down deep behind the fundus. The intermittent pressure previously described is now renewed, the uterus being pressed from before backward. This procedure should be repeated six to twelve times.
    These procedures, must be executed with the greatest care to avoid giving the patient pain, thereby exciting contraction of the abdominal muscles, which necessarily interferes with the manipulation.

471
    3. Digital Kneading of the Uterus. - The fingers of the left hand being returned to the first position behind the cervix, thus supporting the organ, the fingers of the right hand execute a circular digital kneading movement, beginning at the top of the fundus, and enlarging the circle until the fingers are made to press down the sides of the uterus and all about it. A slight change in the direction of the pressure made by the fingers of the left hand enables them to antagonize constantly the movements of the right hand, so that the uterus may be by this means very thoroughly manipulated in nearly all cases, and except in patients who are very fleshy. This procedure is continued from one to five minutes.

472
    4. Lifting Movements. - The preceding manipulations will have completely freed the uterus from the overlying intestines, so that the top of the fundus will be lying in immediate contact with the peritoneal surface of the anterior wall of the abdomen. By the combined action of the internal and external hands, the uterus can now be freely lifted forward so that its form may be easily outlined by the fingers of the right hand. The action should be intermittent.

473
    After lifting it forward as far as possible without inconveniencing the patient, the uterus is released, and allowed to drop down, then again lifted, the action being repeated six to twelve times, at intervals of two to three seconds, the uterus being held forward for a like period. The purpose of the lifting is to bring the blood vessels under tension, thus emptying the venous sinuses, which are filled with fresh blood as the uterus returns to its former position.

474
    5. Vibration of the Uterus. - While supporting the organ with the fingers of the left hand behind the cervix, the thumb or one or more fingers of the right hand, is applied to the top of the uterus, and fine vibratory movements are communicated to it. This is a powerful means of stimulating the uterine circulation.

475
    6. Digital Kneading of the Appendages. - In pelvic massage the manipulations should not be confined to the uterus alone. The ovaries, tubes, and the broad and round ligaments may be masséed thus: After lifting the uterus well forward, freeing it from the overlying intestines, the fingers of the left hand are directed toward an ovary. Starting as low down as possible, firm pressure is made in an upward direction, while the fingers of the external hand are made to cooperate in an effort to grasp beneath the ovary and tube and lift them forward. At the same time, gentle digital kneading movements are executed, the pressure of the external (right) hand being directed toward the fingers placed internally.

476
    7. Digital Kneading of the Round Ligaments. - The fingers in the vagina should be directed toward the inguinal canal while digital massage is executed by the fingers of the right hand traveling in a curved line from the external ring along the side of Poupart's ligament and toward the fundus. The internal fingers will, to some extent, follow the movements of the right hand, so as to compress the tissues between the fingers of the two hands.

477
    8. Stretching of Adhesions and Kneading of Exudates. - When adhesions and exudates are present, firm pressure should be made directly upon the bands of adhesion or the masses of exudate
with the tips of the fingers which operate internally, counter-pressure being made externally; and, so far as possible, the morbid parts should be grasped between the fingers of the two hands, and thus subjected to digital massage. Adhesions are also stretched by the lifting movements of the uterus previously described.

478
    9. Nerve Compression. - The sacral plexus of the spinal nerves and several of the lowermost pairs of' ganglia of the sympathetic are accessible to digital pressure through the vagina; and in appropriate cases these, as well as other nerve structures, may be stimulated by gentle compression in connection with other procedures. One of the largest nerve masses accessible to compression through the vagina is the hypogastric plexus, which is located on the anterior surface of the sacrum,
just below the promontory. A row of four or five sympathetic ganglia lies on either side of the median line just over the junction of the sacrurn and the ilium, the anterior aspect of the sacroiliac synchondrosis. A single ganglion (coccygeal ganglion, or ganglion impar) lies in front of the coccyx. Pressure made upon these points stimulates the ganglia and their branches, and by this means excites the circulation in the pelvic vessels.
    Nerve compression in this region, as in other parts of the body, must be applied with very great discretion. This procedure should never be employed in cases in which inflammation, active congestion, or excessive hyperaesthesia exists. It is only appropriate in cases of passive congestion, atony, subinvolution, and general relaxation of the parts.

479
    It is generally well to alternate some of the above-described procedures, especially the lifting and kneading movements, instead of adhering closely to the order in which they have been given for the purpose of precise description.
    Upward deep kneading movements executed with the closed fist may be advantageously alternated with the other movements mentioned.

480
    10. Massage of the Abdominal Muscles. - After the internal manipulations, the muscles of the lower abdomen and inner thighs should be gently masséed. The procedures most useful are the following, employed in the order named : Tapping, hacking, spatting, centripetal friction, and finally, stroking.
    11. Finishing movements:

481
    (1) Knees separating, breathing. The patient should inspire while separating the knees, and expire while closing them. The vigor of the exercise may be increased by making a slight resistance to the movements of both adduction and abduction (Fig. 71). The movements should be made at the rate of ten to twelve per minute.

482
    (2) Hips raising (Fig. 82), breathing in as the hips rise, and breathing out as they sink. This movement should be repeated from four to eight times. The movements of knees separating, hips raising, and breathing may be executed simultaneously.

483
    (3) The treatment should be concluded by having the patient turn upon the face, and administering percussion - tapping, hacking, spatting, beating, and clapping over the sacrum and fleshy portions of the hips.

484
    The following, points should be carefully observed in the administration of pelvic massage:
    1. Never administer pelvic massage to erotic patients, nor in cases of vaginismus, acute pyosalpinx, pelvic abscess, growing tumors of the uterus or ovaries, rectal ulcer, acute vaginitis, irritable urethra, or inflammation of Skene's glands, until after these conditions have been removed. The best results are obtained in cases of subinvolution of the uterus, relaxed ligaments, recent exudates, and passive congestions with little sensitiveness. Kesch recommends that uterine massage should be applied especially during menstruation, but does not give what seem to the writer to be valid reasons for the recommendation. My opinion is very positive that massage should be discontinued during this period.
    2. Before treatment, have the patient thoroughly empty the bladder and bowels, employing an enema, if necessary, or a coloclyster (large enema in right Sims's or in knee-chest position). A hot vaginal douche should also be administered.
    3. No movements should be made with the hand used internally except with the ends of the fingers.
    4. The force employed should generally be sufficient to produce slight pain.
    5. In cases of flexion, the flexion should, if possible, be straightened during the manipulation. In all cases of displacement, the uterus must be restored to proper position.
    6. Care must be taken to have the patient breathe deeply and regularly during treatment.

485
Massage of the Prostate. - In cases of enlarged prostate due to thickening from inflammation especially in recent cases, much can be accomplished by massage properly administered. Massage of the prostate should be preceded by abdominal massage, and, followed by inspiratory lifting, deep breathing, and percussing the sacrum (313-317).
    1. Introduce one, or better two, fingers, well oiled, into the rectum, making firm pressure against the prostate, but taking care not to press so hard as to bruise the membranous urethra. With the right hand, make pressure just above the pubes. After pressing the parts for two or three seconds, allow a rest for an equal period, repeating the pressure from six to twelve times.
    2. Make gentle friction over the prostate in a downward direction for the purpose of pressing out of the ducts the stagnant secretions.
    3. Make gentle friction over the prostate by pressure of the fingers, moving from below upward, covering the posterior surface of the organ, to empty the blood-vessels.
    Care should be taken to have the patient empty the bowels and bladder thoroughly before the treatment is applied. Sometimes the patient is unable to completely empty the bladder; in such cases a catheter should be passed.

486
    Massage of the Coccyx. - This procedure is useful in cases of coccygodynia accompanied by painful points adjacent to the coccyx or its ligaments. The bowels and bladder should be first emptied, as in all forms of pelvic massage. Proceed as follows
    1. With the patient in the right Sims's Position, pass one finger, or better two fingers, of the left hand into the rectum applying them to the anterior surface of the coccyx. With the fingers of the other hand applied externally, make a suitable degree of pressure, and knead the affected parts between the fingers, giving special attention to points of induration or pain. In cases in which the parts are extremely tender, begin the movements at a little distance from the most painful points, gradually encroaching upon the more sensitive tissues. The manipulation may be continued for three to ten minutes.
    2. Apply to the sacrum, tapping (313) and hacking (316) movements; to the more fleshy parts, clapping (315), spatting (314), and beating (317).
    3. Employ deep vibration, placing the hand over the lower end of the spine (302).
    4. Apply stroking with the palm of the hand from the coccyx upward, outward, and downward .along the inner surfaces of the thighs.

487
    Massage of the Rectum. - This procedure is useful in cases in which the sphincter muscle is relaxed, and applicable to many cases in which the muscle has been over-stretched by officious and unnecessary dilatations applied by so-called "orificial surgeons." The most important movements are the following:
    1. Percussion with the finger tips, tapping (313).
    2. Fulling (244) about the verge of the anus, care being taken to avoid bruising the parts, which should be well lubricated. The manipulations should be very delicate, the tissues being carefully picked up with the ends of the fingers and thumbs.
    3. Thumb kneading of the anus and the tissues immediately adjacent, care being taken to roll the parts in when they are everted.
    4. Hacking (316).
    5. Beating (317).
    6. Pressure (154) and vibration (302). Firm pressure with the palmar surface of the fingers or with the closed fist in an upward direction, accompanied by a vibratory movement.
    7. Percussion of the sacrum and hips, as in massage of the prostate and coccyx (485, 486).
    8. Inspiratory lifting (467).
    Massage of the rectum should be preceded by abdominal massage. This procedure, as well as the following, is seldom required.

488
    Massage of the Vagina. - This procedure is useful in cases of rectocele, cystocele, and relaxed vagina, and is applicable to cases in which for any reason a suitable surgical operation cannot be performed. It is also valuable in cases of rigidity of the perineum, as a preparation for confinement, for which it may be employed daily during the last six or eight weeks of pregnancy. It should be resorted to in all cases of pregnancy in which there has previously been an operation for repair of the perineum. Proceed as follows:
    1. Lifting abdominal contents (465).
    2. Lifting uterus and appendages (472), two fingers of the left hand being placed internally, the other hand cooperating externally, as in massage of the uterus.
    3. With patient in knee-chest position, lift the bowels (466).
    4. With knee-chest or Sims's position, fingers placed upon thighs, tips of thumbs at the mouth of the vagina, roll the tissues in as much as possible, lift upward, and manipulate the perineum with the thumbs.
    5. With the index finger of the left hand in the rectum and the thumb in the vagina, compress and knead the posterior wall of the vagina.
    6. With the closed fist firmly placed upon the perineum, make strong vibratory movements (302).
    7. Apply percussion to the sacrum and the buttocks (483).
    8. With patient lying upon the back, the heels well drawn up, raising of hips and full breathing (482).
    9. Knees separating and breathing, with resistance (481),
    10. Inspiratory lifting (467).

489
    Massage of the Face. - This procedure is useful for developing the muscles of the fleshy portion of the face, improving the circulation (hence the complexion), removing wrinkles, especially about the eyes and the corners of the mouth, and also relieving facial neuralgia and muscular twitching.

490
    For persons with fleshy faces, about all that can be done by general facial massage is to knead the tissues by compressing them with the thumb and fingers against the underlying bony surfaces, working outward from the mouth, the nasal openings and the eyes. Care should be taken to work toward the points at which the blood vessels emerge.

491
    In persons with thinner faces, the tissues of the cheek may be grasped between the thumb and finger. When indurations are present, the protected finger may be introduced into the mouth and placed against the cheek, while massage is applied with the tip of the thumb or with the fingers of the other hand. The little finger, covered with soft cotton, may be introduced into the nose and ears, although this procedure is very seldom required. Make use of the following manipulations:

492
    1. Digital kneading, working outward from the eyes, nose, and mouth, at which points many muscles find their insertion.
    2. Petrissage, or grasping-kneading of the muscles of the face.
    3. Massage of the orbit (Fig. 101), care being taken to avoid the eyeballs. Place one thumb upon the lower lid and the other just beneath the eyebrow, within the margin of the orbit. Make traction outward, drawing upon the inner corner of the eye ; then change the position of the thumbs so as to massér all the muscles about the eye. Massage about the eye improves both the nerve and the muscular tone of the eye, and in this way often relieves muscular asthenopia, frequently due to general weakening of the eye, which renders annoying or injurious slight muscular inequalities which are not noticeable when the muscles are well developed. The attention of those neurologists and oculists who think it necessary to operate upon every case of muscular asthenopia is especially called to this statement. The habit of rubbing the eye for relief, which prevails almost universally among persons thus suffering, is a strong suggestion of the utility of massage administered systematically and in a skillful manner.

493
    Special attention should be given to the nose, working from the root of the nose downward and outward. Relief is often afforded in cases of nasal obstruction from catarrh by facial massage, which is due to the fact that the lymphatics of the face arise from the mucous membrane of the nose.

494
    Massage for Wrinkles. - Facial massage may be made useful in removing wrinkles (Figs. 99 and 100), which as often indicate unhealthy tissues as advancing age or a wearisome existence. Wrinkles are best relieved by making traction upon the skin in a direction at right angles with the wrinkles, the wrinkled part being thoroughly manipulated to restore the natural flexibility of the skin, which has been lost. The patient must also be taught how to smooth out the wrinkles by cultivating a suitable facial expression. For example, the vertical wrinkles of discontent or despondency may be made to disappear by smiling, which wrinkles the face in an opposite way.

495
    In friction of the face, special care should be taken to avoid making so great pressure as to cause irritation of the skin.

496
    Compression of the nerve trunks which supply the face is a valuable procedure in many cases. The chief points to which pressure should be applied are shown in Fig. 32.

497
    The different useful procedures in general facial massage may be applied in the following order :
    1. Digital kneading of the cheeks, nose, and orbit.
    2. Petrissage.
    3. Stroking, localized as may. be indicated when wrinkles are present.
    4. Ear rolling (503 [3]).
    5. Stroking along the inferior border of the lower jaw.
    6. Friction of the neck (433, 435),

498
    Massage of the Eye (Fig. 102). - Massage of the eye was first suggested by Donders. The writer first saw it applied by Landolt, of Paris. It has been found to be useful in ulceration and cloudiness of the cornea, hypopyon, and in the early stage of glaucoma. Massage of the eye increases the vascularity of the eye, and encourages drainage.

499
    Reibmayr noted that when masseing one eye, the other eye became, during the first minute, dilated; second minute, contracted; while in the third minute, the pupil of the eye masséed became smaller than the other, showing that massage of the eye, through reflex action, affects the controlling nerve.centers as well as the eye itself.

500
    Massage of the eye must be applied with very great delicacy of touch. Proceed as follows: Have the patient close his eye; place the fingers of the hand upon the temple a short distance from the orbit, and the tip of the thumb upon the upper lid of the closed eye. Make gentle rotary movements, gradually increasing the pressure, but taking care that it be not so great as to cause pain. Patients whose eyesight is impaired often remark that they are able to see better after the application.

501
    Massage of the Ear (Fig. 103). - This procedure is of great value in middle-ear disease, catarrhal disease of the Eustachian tubes, in chronic disease of the middle ear unaccompanied by suppuration, and in cases of perforated membrana tympani. It may also prove useful in cases of tinnitus aurium.

502
    Politzer recommends derivative massage as a means of relieving the pain of otitis media and of furuncles. In case of acute inflammation, the manipulations should be confined to the tissues about the ear, avoiding the ear itself.

503
    The following procedures are the most effective:
    1. Digital kneading, friction, and stroking about the ear, - in front, behind, and beneath. This  procedure is especially useful as a derivative measure.
    2. Intermittent pressure upon the tragus in such a manner as to close the external meatus. The pressure should be both applied and withdrawn suddenly, but without too great force. The rate should be sixty to one hundred per minute. Its purpose is to exercise the structures of the middle ear.
    3. Ear rolling (Fig. 103), with the fleshy portion of the thumb applied to the ear in such a manner as to cause it to fit into the external ear, and close the orifice; the right hand to the left ear of the patient, and the left hand to the right ear. By means of a rolling movement, the ear will be stretched in different directions, and the meatus may be opened and closed in such a manner as to secure alternate compression and rare-faction of the air in the external auditory canal, thus imparting movement to the membrana tympani and to the ossicles connected with it. This measure may, often replace the mechanical means ordinarily used for treating the middle ear.
    4. Stroking of the Eustachian tube, by pressing one or two fingers into the furrow behind the maxillary bone, starting close to the ear, and following the groove down beneath the jaw. By pressure thus applied to the Eustachian tube it may be emptied of obstructing mucus; and when in a state of chronic inflammation, useful reparative processes are set up. An itching in the throat from which many patients complain is frequently due to an irritation at the orifices of the Eustachian tubes, which may be readily relieved by this means.

504
    Massage of the Larynx (Fig. 104). - This measure is especially valuable in chronic disease of the larynx, particularly in cases in which the vocal cords are relaxed, or in which there is weakness of voice from insufficient development of the laryngeal muscles. The object aimed at in massage of the larynx is to relieve congestion, if it exists ; to improve the blood and lymph circulations, stimulate nutrition, and thus strengthen the muscles and the nerve supply of the part..

505
    The following are the most useful procedures:
    1. Derivative massage of the neck (433, 435).
    2. Fulling (244) of the skin overlying the larynx.
    3. Digital kneading (268), in which the fingers are worked into all the irregularities of the larynx, and between it and the surrounding tissues.
    4. Lifting, in which the larynx is seized between the thumb and finger just below the pomum Adami, and crowded upward. The vigor of this procedure may be increased by holding the larynx up while the patient swallows.
    5. Tapping (313).
    6. Deep vibration (seize larynx and vibrate) (302).
    Friction strokes, are intermingled with the other measures mentioned.

506
    Massage of the Heart. - The position of the heart would seem to render it inaccessible to the application of massage; but Oertel, in 1889, contributed to the literature of massage, a paper upon "Massage of the Heart, " in which he claims to have obtained great advantage from the use of massage in such a manner as to influence the heart directly. He employs massage of the heart especially in connection with his system of treatment by mountain climbing, and considers it indicated in the following conditions :
    1. When the heart muscle is weak, either as the result of anaemia, impaired nutrition, or obesity.
    2. When the arteries are imperfectly filled, resulting in passive or venous congestion.
    3. In cases in which there is mechanical obstruction in the circulation, resulting from valvular lesions, diminution of the respiratory field, pressure of tumors, or anything which increases the work of the heart.
    4. In connection with gymnastics for strengthening the heart.

507
    Massage of the heart is contra-indicated:
    1. In acute or recurring endocarditis or pericarditis.
    2. In myocarditis.
    3. In sclerosis of the coronary arteries and in general arterio-sclerosis.

508
    Massage of the heart is applied during expiration only, and in the following manner: With the patient reclining, the head supported upon a pillow, the masseur stands at his head, and, bending over the patient, applies his hands to the sides of the chest at its extreme upper part, the fingers touching the chest at the axilla, while the thumbs are directed toward the sternum (Fig. 105). The patient should be instructed to breathe deeply, slowly, and regularly. At the end of inspiration,. and just as the act of expiration begins, pressure should be made with the hands, which at the same time should move gradually downward and forward until the thumbs fall upon the xiphoid cartilage (Fig. 106). The effort should be made to narrow the chest laterally, and at the same time to compress it antero-posteriorly. It is especially important to prevent increase in the antero-posterior diameter of the chest during expiration. The application of pressure should be gradual, increasing as expiration proceeds and as the hands glide downward. The greatest force should be applied between the fifth and eighth ribs, the maximum of pressure falling over the latter.

509
    Massage of the heart is beneficial:
    1. In completing the act of expiration.
    2. Through direct pressure made upon the heart, whereby its nutrition is favorably influenced, as in massage of other muscles.

510
    Massage in Scoliosis. - Apply massage (426) only after first putting the patient into a correct position. The following procedures are helpful in accomplishing this: In mild cases, patient lying on face, arms stretched upward; in cases in which the patient has lost the power to correct the deformity by voluntary effort, side lying on quarter circle, concave side uppermost. Massage may also be applied with the patient suspended by head and shoulders, or hanging by the arms.

511
    Untwisting the Patient. - The patient, sitting, passes the arm of the high side in front, with the hand on the opposite shoulder; while the hand of the low side is passed behind, and rests upon the back. Useful in cases of rotation.

512
    Three degrees of deformity may be described:
    1. Deformity reducible by the patient's unaided, voluntary efforts.
    2. Deformity readily reducible by manual assistance or such mechanical assistance as the patient can apply.
    3. Deformity irreducible by manual assistance, and not easily reducible by mechanical aid.

513
    The first class is curable; the second class may be curable, and can certainly be benefited; the third class is incurable, but may possibly be somewhat improved, and will require the permanent use of mechanical support.

514
    Method of Testing the Patient's Ability to Correct Deformity without Assistance.
    1. Give usual directions for correct standing (575) (Figs. 108,109, and 110).
    2. Rest-standing position (hands at back of neck, arms in line ).
    3. Standing, arms stretched upward.
    4. Rest-close-standing ( heels and toes together).

515
    Exercises . - The following exercises are valuable for patients of this class, to be used in connection with massage:
    1. The patient sitting untwisted (511), leans forward, then raises the body backward against resistance applied to the head.
    2. The patient sitting untwisted, operates a pulley weight with each hand.
    3. Rowing, sitting on an inclined plane, high side of body on high side of seat.
    4. Sitting on an inclined seat, untwisted, use pulley weights in opposite directions, high side pulling down, low side pulling up; high side pulling from behind, low side from in front; both sides simultaneously pulling from opposite sides toward the body.
    5. Hanging from swinging rings or "ladder-wall, " the low side grasping higher than the high side.

516
    Method of Correcting Curvature by Manual Assistance.
    1. For posterior curvature, patient should bend forward at hips, holding hips back. As the patient rises, press upon the convexity of the curve; and tell him to raise the chest, and draw the head back and the chin in.
    2. Patient should take downward-bend position; one side of back higher than the other indicates rotation (see accompanying cut). Masseur, placing one hand upon highest part, and having the patient rise, should at the same time make gentle resistance.
    3. Patient should stand facing the table, thighs touching the table, and bend forward at the hips; head erect, chin well drawn in. Masseur should place his hands upon the convexity of the curve, and have the patient raise the trunk backward.
    4. Patient standing, the masseur should place one hand on the convexity in front, the other on the convexity behind, and stroke with firm pressure from before backward. If necessary, repeat with the patient in rest-standing position, or rest-forward-bend standing. (**These and other gymnastic positions are fully explained in another work by the author, now
nearly ready for publication.)

517
    In applying massage to the back in scoliosis, particular attention should be given to percussion, especially of the concave side. Use all the different kinds of percussion movements. Make pressure upon the prominent surfaces. Endeavor to work the spines into position by pressure and manipulation with the thumbs. A daily hot and cold douche or sponging of the back is of great importance in these cases, as a means of stimulating the nutrition of the tissues.

518
Massage of the Joints. -There is no single class of cases in which the benefits derived from massage are more evident than in those of chronic joint disease or of recent injury to the joint; at the same time there is no one class of cases in which large discretion and experience are of greater importance. Excessive manipulation of an irritable joint or of a joint the ligaments of which have recently been injured, as in case of a bad sprain, may do almost irreparable injury, and will certainly subject the patient to a great degree of unnecessary suffering, and may discourage him altogether, thus depriving him of the great benefits to be derived from massage skillfully administered. It may be laid down as a principle, that massage of the joints should never be applied in such a manner as to produce any considerable degree of pain. Slight pain is often produced by the first manipulations, especially in cases in which there has been much loss of motion, but the pain thus induced should be of a transient character, subsiding within a short time after the manipulation. When the pain increases for some days afterward, the manipulation has been applied in a violent or bungling manner, or the application should have been derivative rather than made directly to the joint.

519
    A matter which requires the most careful discrimination is that of determining when manipulations should be applied directly to the joint, and when above or below it. Briefly, the best advice upon this point is this: When a joint is very sensitive, derivative massage only should be employed for a week or ten days at the beginning, the manipulations being gradually brought nearer the joint from day to day.

520
    A careful examination of the tissues in a case of chronic rheumatism of a joint will show rheumatic nodules lying along the course of the lymphatics above the joint. In a fleshy person it is not always easy to find these, but a delicate touch will generally discover them. The work should begin upon the tissues above the joint for the purpose of opening up these obstructed channels, and thus acting indirectly upon the lymphatics and blood vessels of the joint.

521
    The derivative effects may be greatly increased by giving special attention to the healthy joint next above the affected joint, in the employment of strong traction, pressure, and other joint movements. The lymph and blood channels are largest in the vicinity of the joints, and by acting upon these by means of joint movements, pressure, and manipulations, the vessels of the joint below may be drained, especially after the lymph channels connecting the two have been opened up.

522
    It must not be forgotten that in cases of chronic joint disease the muscles and other tissues about the joint are affected, as well as the joint itself. This is especially true of chronic rheumatism, and is evidenced by muscular atrophy, induration, or fatty degeneration, one or the other of which conditions is nearly always present in chronic joint disease.

523
    It is useful to know that certain muscles or muscular groups suffer more than others in connection with joint disease. For example, when the knee is involved, the quadriceps atrophies; in hip joint cases, the glutei muscles are chiefly affected; in cases of the elbow, the biceps and the brachialis anticus; in cases of the shoulder, the deltoid and supra- and infra-spinatus.

524
    In derivative massage (238), fulling friction, and deep kneading are most effective. In the manipulation of a joint, begin with light friction and pressure. If these applications are tolerated, add digital massage, working between the ligaments, and following all the irregularities of the ends of the bones and the articulating surfaces so far as accessible. Later, add percussion, first tapping, afterward hacking.

525
    Joint movements should be employed from as early a period as possible in cases of joint disease, so as to prevent the limitation of movement, or to restore motion which has been lost. The application must at first be very gentle indeed, and should not be carried to such an extent as to produce continued pain. The derivative manipulations which are first employed should be continued in connection with applications to the joint, since the effect of kneading a joint is to increase the circulation through it; while the effect of derivative massage is not to carry the blood through the joint, but rather around it, thus relieving excessive local congestion, or hyperaemia, by diverting the blood into other channels.

526
    By the combination of local and derivative massage applied in connection with compression of the joints and gentle joint movements (342), the vital activity of the part may be greatly increased. In cases of extremely painful joints in which beat and congestion are marked symptoms, derivative massage may be employed upon the soft parts both above and below, and joint movements should be applied to the joint above, care being taken to avoid motion of the affected joints.

527
    Centripetal friction applied to the tissues and next joint above, relieves painful joints by increasing the surface circulation, and so diverting the blood from the joint itself. Downward stroking below the joint also affords relief by lessening the supply of blood to the joint.

528
    The cautions which have been given respecting the manipulation of affected joints, apply, of course, only to those in which the disease is active, or to painful or congested joints. In many old cases of joint disease there is; a decreased vascularity and also a morbid and decreased secretion, as is evidenced by a grating, snapping noise, and other sounds induced by motion of the joint. When this condition exists, the massage should be applied directly to the joint itself. Even though it should have the effect to slightly increase the pain at first, the ultimate result will be improved nutrition of the joint, and the restoration of the normal secretion. I have seen some most remarkable results in cases in which improvement would certainly, have been regarded as most improbable.

529
    In rheumatic gout and in old cases of rheumatism, very persevering efforts are required. The maximum amount of benefit to be derived from massage is not always obtainable except by its continuous employment for several months, and sometimes even two or three years. In one case under the writer's care, a lady who had suffered from rheumatic gout for many years, the limbs were flexed to nearly a right angle, and the patient had despaired of again standing up_right ; but at the end of two years she was able to walk erect without the aid of a cane.

530
    In cases of chronic rheumatism and rheumatic gout, it must be remembered that the patient is suffering from a diathesis, and that the disease is not a purely local malady; consequently, general massage, hydrotherapy, proper regimen, and other measures must be combined with the local treatment.

531
    It is of great advantage also, to employ local applications of electricity as well as hydrotherapeutic measures, in these cases. The irritation occasioned by manipulations is usually promptly relieved by a hot fomentation, followed by a heating compress, which should be applied thus: Wring a linen towel out of water as cold as can be obtained. If the patient is feeble, it should be wrung dry ; in a more vigorous person, a larger amount of water may be retained. The towel is wrapped tightly about the joint, and is then covered with oiled muslin, and closely wrapped with several folds of flannel, which should be applied in such a manner as to prevent any air from reaching the moist surface. It is generally well to change these compresses three or four times a day. When there is considerable heat, in the joint, they may be changed more frequently with advantage.

532
    In old cases in which the tissues are much relaxed, or in which secretion is deficient, the hot and cold douche is the most effective means of stimulating the vital activities of the joint. Massage and hydrotherapy combined are twice as beneficial in the treatment of chronic joint, troubles as either used alone. Together they are capable of effecting a cure in every case in which a cure is possible.

533
    Massage for Sprains. - The treatment of sprained joints by massage is by no means a recent idea. Massage has been thus employed in Germany for more than thirty years, and was used in England half a century ago; but the method is so diametrically opposed to that in common use by the profession, that it has been but slowly adopted. It also requires special skill, while the employment of, the old method of immobilization is compatible with any degree of ignorance and stupidity.
    The value of this method is now so well established that it is not necessary to offer statistics in support of it. Any physician who has once had the satisfaction of seeing the victim of a severe sprain walking about without inconvenience at the end of a week or ten days, who under the old regime would have been crippled for months, and possibly have suffered the loss of a limb, will require no further argument to convince him of the efficacy of this mode of treatment. Much skill and experience are needed, however, to enable a masseur to accomplish a rapid cure.  The following is the method:

534
    Apply massage as soon after the injury as possible, beginning with derivative manipulations of the soft parts above the affected joint and of the joint next above it. Centripetal friction, with quite firm pressure, applied very carefully, may be advantageously employed upon the joint itself from the very first, but other manipulations of the joint itself should be deferred for a day or two. The derivative manipulations should gradually approach the joint from above, until by the second or third day the joint itself is reached.

535
    Careful joint movements should be executed after the second day, pains being taken not to carry flexion or extension so far as to produce the feeling of resistance, as this will bring a strain upon the bruised or lacerated ligaments or pressure upon the injured articulating surface. If there is much swelling, the external tissues are probably the chief seat of injury. Both external and internal parts may be injured.

536
    At first, when the manipulations are very light in character, the massage should be applied twice daily; later, when more vigorous measures of treatment are employed, once a day is sufficient. After each manipulation apply a tight bandage, taking care to begin the bandage at the toes. If there is much pain, apply a hot pack, followed by a cool compress, for an hour; or place the feet in hot water, and gradually increase the temperature until it is as hot as can be borne. Continue bath for fifteen minutes. This is an excellent means for relieving local congestion. It may be used once or twice a day, the bandage being applied immediately after the bath.

537
    I think it very advantageous to employ these hydrotherapeutic measures in connection with massage. Cold water has been much recommended in the treatment of sprains, and has certainly been highly successful, although less rapidly curative than massage. By the combination suggested, most rapid results may be obtained, and the, patient may be saved from great and prolonged suffering.

538
    Muscular Rheumatism. - In muscular rheumatism, pain is occasioned by use of the affected muscles. There is often also considerable loss of both motion and elasticity in the muscle.  Frequently, rheumatic nodules will be found along the course of the lymphatics. Muscular rheumatism may exist alone or in connection with a like affection of the joints, as in the last_named disease the rheumatic process not infrequently extends from the joint to adjacent muscles.

539
    Daily manipulation is essential in the treatment of muscular rheumatism. The most important procedures are friction, deep kneading, hacking, rolling, wringing, chucking, stretching, and such resistive movements as will act upon the affected muscles, together with movements of the joint acted upon by them.

540
    Fomentations and heating compresses are of special value in these cases. Rheumatism of the muscles, as well as of the joints, is connected with a systemic condition, or diathesis, which must also receive attention. Not infrequently in the majority of cases, in fact there is to be found dilatation of the stomach; and complete relief will only be obtained by a combination of local
measures with such general treatment as will correct the constitutional condition, which includes careful adaptation of the diet to the state of the digestive organs, and an antiseptic regimen. Local treatment of the stomach is essential in many cases, also general tonic and eliminative measures.

541
    Massage of the Breast (Figs. 111 and 112). - The procedures in massage of the breast consist of gentle grasping, compressing, rubbing, and fulling movements, beginning at the periphery of the breast and working toward the nipple. The manipulation is very similar to that usually employed in milking. The parts should be thoroughly lubricated, and care taken to avoid so great pressure as to bruise the tissues. The manipulations should not be employed when the breast does not contain milk, as harm will thus be done rather than good. The purpose is to remove the milk from the obstructed channels in the gentlest manner possible, and thereby relieve the over-distended ducts. When hardness of the breast exists in the puerperal or nursing woman, milk is almost always, present, although the patient may feel very certain to the contrary. .

542
    It is, as a rule, improper to manipulate a breast when suppuration exists. It should not betaken for granted, however, that suppuration is present because the patient has had a chill, and shows a rise of temperature, as the application of massage, even under such circumstances, will often result in resolution. But the greatest utility of massage of the breast is as a means of preventing an over_accumulation of milk, with resulting chill, fever, and suppuration. Violent or bruising manipulations, however, may result in great damage, encouraging suppuration rather than preventing it.

543
    Manipulation of the breast is sometimes employed as a means of encouraging development of the organ, especially in cases in which the nipple is unusually small or retracted. In applying massage for this purpose, the areola should be drawn back by pressure with the thumb and forefinger until the nipple becomes prominent.. It should then be seized and drawn forward, as by the action of the child's lips when nursing (Fig. 112), a pinching and rolling movement being at the same time applied. The proper time for such applications is during the later months of pregnancy. It should be remembered, however, that manipulation of the breast sometimes, has an exciting effect upon the pelvic organs, and any marked indication of such a result should be considered sufficient reason for discontinuing the applications. This treatment is also an excellent means of hardening the skin of the breast and the nipple, and hence is a useful precaution against soreness of the nipples from nursing.

544
    Massage in Pregnancy. - Massage is a most valuable means of preventing a variety of the most serious complications of pregnancy and parturition. A woman who is accustomed to active muscular employment during the period of gestation will not require the assistance of massage; but for those women who lead sedentary lives or who are lacking in physical development, massage affords a most excellent measure of preparation for the parturient process. Both general and local massage are of value in these cases. General massage should consist of the ordinary procedures, with this exception Special care must be taken to avoid violent manipulations of the abdomen and too vigorous percussion of the lower portion of the back, especially at the beginning of the treatment. The "deep " procedures in massage should not be undertaken unless the masseuse has had special experience in these cases, and knows how to reach the colon without disturbing the gravid uterus. The chief aim of the manipulations should be to develop the muscles, and hence they will principally consist of fulling movements and petrissage of all the muscular structures of the abdominal wall. Lifting of the abdominal contents will also be found extremely useful in many cases, relieving the strain upon the back, and aiding in the "rising" of the uterus, which is likely to be delayed in women of feeble muscular development, resulting in many distressing pelvic symptoms.

545
    Massage of the Perineum. - This procedure is especially valuable in cases of rigid perineum, and cases in which a laceration has previously occurred and has been repaired by an operation. By suitable manipulations, the parts being thoroughly lubricated, the structures of the perineum may be rendered stronger and more elastic, so as to be able to bear a larger amount of stretching. The applications should be as follows: With the patient lying upon her side, in the left Sims's position, the operator stands facing the back, with the fingers resting upon the buttocks, and manipulates the perineum, using the thumbs in alternation, stretching the tissues away from the median line. Only one thumb should be used at once, stretching in opposite directions, as by the use of both, the stretching might be overdone and the skin irritated.

546
    The patient should also be made to execute breathing movements in which both the abdominal and the perineal muscles are vigorously contracted during the act of expiration. Under the instructions of a physician, the manipulations may be somewhat extended and varied by introducing the forefinger into the vagina or the rectum, the muscle being grasped between the forefinger and the thumb, and thoroughly pressed and stretched.

547
Neuralgic Pain. - Massage is one of the most effective means of relieving neuralgic pain. General massage acts by improving the blood and the general nutrition. Dr. Chapman has very well said that "pain is the cry of a hungry nerve for better blood." With better blood and better nutrition, the cause of neuralgic pain is usually removed. Local massage may act both as a derivative measure and as a means of directly stimulating the nutrition of the nerve itself, according as the applications are made in a derivative manner or applied directly to the nerve.

548
    All the various procedures of massage may be used in the treatment of neuralgia. The most effective measures for direct application are nerve compression and vibration. Vibration may be employed either by manual or mechanical means. Mechanical vibration may be simply ordinary shaking, or what may be termed musical vibration. Musical vibrations were first employed and brought to the attention of .the profession by Mortimer Granville, of London, whose "nerve percuter" the writer has had in use for some twelve years. Dr. Granville believes that pain is due to disharmony, or morbid vibration, in a nerve, and has found in his experience that acute, sharp pain is best relieved by musical vibration of a low tone, while dull, heavy pain is best relieved by high-keyed vibrations. He thinks that relief is obtained by interruption of the discordant nerve vibrations, which he considers the cause of the pain.

549
    Charcot claims to have obtained good results with the vibrating helmet for relief of painful head symptoms. I have not found Mortimer Granville's nerve percuter entirely satisfactory, as it is very prone to get out of order, but have obtained good results from the use of a percuter constructed by modifying Bonwell's dental engine. The writer has recently had constructed an electrical device by which vibrations may be applied directly to a nerve trunk, or to any desired point accessible from the surface of the body. (See Fig. 121.)

550
    Writer's Cramp. - This disease, which appears under various forms, and to which different terms are applied as it occurs in writers, telegraph operators, piano players, or persons engaged in other occupations which chiefly employ the muscles of the forearm, is more amenable to massage than to any other mode of treatment. Three distinct phases are described, characterized respectively by trembling, spastic contraction of the muscles, and paralysis. All three phases of the disease are sometimes found present in a single case. This condition is largely the result of unbalanced muscular and nerve action.

551
    The following procedures are the most effective in relieving it:
    1. Thorough kneading of the fingers and dorsal interossei (213, 274).
    2. Kneading of the palm (275), especial attention being given to the fleshy masses of the palm of the hand ; and rolling of the hand (Fig. 47).
    3. Kneading of the forearm with very firm pressure (277).
    4. Hacking (316) of forearm and arm.
    5. Stretching of the finger, wrist, elbow, and shoulder joints (342, 372_376).
    6. Vibration-shaking (303).
    Centripetal friction, with firm pressure, should be used in alternation with the various procedures named.

552
    In addition to the passive movements of massage, the patient should be directed to take special exercises. These. exercises should be so directed as to bring into action the muscles which antagonize the affected muscles or those which are most employed in the exercise which has given rise to the disease. In writing, the interossei are used such a way as to fix and steady the fingers, holding the metacarpal bones tightly together; hence these muscles should be exercised in the opposite direction, which will be accomplished by causing the patient to separate the fingers, at the same time making resistance, which may be offered by grasping the extended fingers between the thumb and forefinger, then directing the patient to spread his fingers, the pressure being carefully graduated to the condition of the muscles, and increased from time to time.

553
    The patient may take the exercise by himself, making resistance with the opposite band, or applying it by means of a rubber band slipped over the fingers. As the muscles gain in strength, a stronger band may be used, or another may be added, the number of bands being increased as the muscles gain in strength. These exercises should be taken four to eight times daily.

554
    Writing exercises are also useful. These exercises should be at first chiefly confined to such letters as give the patient the greatest amount of trouble. They, should begin with black board work, or writing with a pencil in a very large hand. The purpose of this exercise is a double one ; first, to gradually train the muscles to execute proper movements ; and, second, to train the motor centers in the brain, which acquire a perverted habit through the long-continued morbid action of the muscles. As the muscular balance is improved, the letters are gradually decreased in size. Such letters as l and n are good ones for practice. To these, other letters may be added later, such as f, t g, and combinations of letters, as, li, lim, lo, log, fog, fit, etc.

550
    The writer has succeeded in curing some extraordinarily bad cases of this kind which had previously resisted all measures of treatment, including operative .procedures.

556
    Massage in Heart Disease. - There is no condition in which massage is of greater value than in the treatment of disorders of the heart. Space is lacking for a consideration here of the pathology of cardiac disease, nor is it necessary that the masseur should possess this knowledge. It is important , however, that the trained masseur should know that different forms of cardiac disease require very different, indeed actually opposite, applications of massage, so that it is quite possible to do much harm by inappropriate measures, as well as incalculable good by the skillful employment of judicious procedures. For practical purposes, the various forms of cardiac disease may be classified in relation to the indications for the application of massage, as follows:

557
    1. Overaction of the heart, due to overcompensation from valvular disease, to disease of the lungs in which the respiratory field is lessened, or to hypertrophy, the result of overtraining. Excessive action of the heart is indicated by its heavy beating (not palpitation, but excessive force of beat), strong, full, and sustained pulse, and congestion of the head, often accompanied by insomnia.

558
    2. Weakness of the heart, a condition resulting from dilatation from advanced valvular disease, from fatty degeneration, or from hemorrhage or long existing and exhausting disease, as a prolonged attack. of fever accompanied by high temperature. Heart weakness may be recognized by the feeble, frequent pulse, easily extinguished by pressure with the finger; by the bluish, or cyanotic, appearance of the face or lips; and by the inability of the patient to exercise. to any extent without quickly getting out of breath.

559
    3. Functional disorders of the heart, such as palpitation and intermittent or irregular beating. These troubles are, In the great majority of cases, connected with disturbances of digestion.
    The treatment indicated for there conditions is as follows:

560
    Massage for Overactive Heart. - This condition requires, first of all, rest in bed. Massage is essential in these cases: (1) To obviate the evils which arise from long-continued rest in bed; (2) to aid in quieting the overactive heart. For the accomplishment of the first purpose, abdominal massage should be administered daily. Moderate breathing exercises should be employed for five minutes before and after each meal, and on first awaking in the morning. The only general procedures which should be employed are stroking (169, 175) and centrifugal friction (194), the purpose being not to accelerate the circulation of the blood in the vessels, but rather to retard it. Care should be taken, even in the application of the measures named, to avoid the employment of too great a degree of force in the friction movements, as the reflex action occasioned thereby may result in giving the treatment an exciting, rather than a sedative, effect.

561
    Massage for Weak Heart. - In cases of extreme. weakness of the heart; that is, cases in which even so small an amount of' exercise as that involved in walking slowly for a short distance, cannot be taken without producing shortness of breath, the patient must first of all be put to bed. He must not be allowed to stand upon his feet at all, nor even to sit up, but must be kept in a horizontal position either in bed or on a cot, or in a reclining chair. In a case of this kind, nearly all the procedures of massage are beneficial, with the exception of centrifugal friction, which should be avoided. The measures of greatest value are centripetal friction (193), respiratory exercises (381-384), joint movements (342-376), and massage of the heart (506-509), all of which should be employed from two to four times daily. Abdominal massage (389-424) should also be applied, care being taken, however, to avoid the use of too much force, as it is not desirable to draw too large a quantity of blood to the abdomen. In joint movements. great care must be taken not to overdo in exercising. The force employed should not be so great as to cause the patient to breathe rapidly. The slightest evidence of breathlessness or quickened respiration on the part of the patient, as shown ,by increased movements of the anterior nares, is an indication that the treatment has been too severe.

562
    In order to avoid the possibility of injury from joint movements, care should be taken not to apply a movement to the same joint twice in immediate succession. Beginning with one arm, apply gentle flexion and extension, first to the wrist, then to the elbow, then rotate the shoulder joint, describing the circle but once; next proceed to the other arm, then take the opposite leg, then the other leg. Now return to the arm first treated, and so continue until each of the extremities has been gone over from two to six times. Centripetal friction should be applied to each limb immediately after the application of the movements, and before proceeding to the exercise of another part.

563
    In employing the flexion and extension, care should be taken that the movement is carried to the extent of quite decided resistance, otherwise the circulation will not be excited. Flexion and extension thus applied to a joint constitute an invaluable pumping process, in which the lyrnphatics and vessels of first one side and then the other are alternately stretched or compressed and emptied, then relaxed and filled.

564
    When the patient becomes able to bear a considerable amount of purely passive flexion and extension without excitement of the heart, the movements should be made at first slightly, and later more strongly, resistive. Resistive movements are most safely and effectively executed in these cases by having the patient first flex the joint to be operated upon, and then attempt to hold it in a flexed position while the masseur extends it ; the, movement is then reversed; that is, the patient extends the limb and holds it rigid while the masseur over-comes the rigidity in flexing it. Very little force should be used at first.

565
    When sufficiently recovered to allow some exercise upon the feet, the patient may be taught to operate upon his own joints by executing flexion and extension movements without the aid of the masseur. This may be accomplished thus: Extending the limb (an arm, for example), the patient renders it rigid by contracting both the flexor and extensor muscles as forcibly as possible. Flexing the joint to the fullest extent, the flexor and extensor muscles are again brought into a state of firm rigidity by voluntary contraction. The movements should be applied in a rotating series, passing rapidly from one joint to another until all the joints of both the upper and the lower extremities have been exercised, and then repeated as directed for passive movements administered by the masseur.

566
    A patient suffering from cardiac insufficiency, as is the case with other patients for whom the "rest_cure " is employed, cannot be cured in bed. The purpose of rest in bed is to restore the balance of the circulation. When this has been accomplished, as indicated by improved aeration of the blood, outwardly manifested by the disappearance of the blue color of the lips or skin, and of oedema of the face or extremities, or of dropsical accumulations in the abdomen and chest or the pericardial sac, the patient may begin to take exercise upon the feet.
    The exercise must not be carried so far, however, as to cause an increase of the dropsical accumulation in the feet or the abdomen. Great care must be taken that the patient does not take such violent or long-continued exercise as to cause breathlessness, or even a decided increase in the rate of breathing. When this precaution is disregarded, the breathlessness will increase from day to day, even though the exercise be not increased, and the patient's former condition will gradually return, necessitating his again being put to bed, and the employment of the same measures as before.

567
    Walking and other voluntary exercises should stop just short of a decided increase of respiratory activity, so that the heart shall not be to any degree excited. The greatest care will be required at the beginning of exercise to avoid going beyond the safe limit.

568
    Passive, active-passive, and voluntary exercise of the joints, with the patient in a horizontal position, should be employed for half an hour after each effort of the patient to become accustomed to exercise in a vertical position, and will be found a very excellent means of quieting the heart. Among the most useful exercises in which the patient may at first engage, is the use of the treadle, which has the motion of the velocipede without the incitement to overexercise which accompanies the use of this admirable means of exercise.

569
    By degrees the patient may be accustomed to more and more severe effort, until such exercises as slowly climbing a hill of moderate grade, or a flight of stairs not too steep nor too long, may be attempted. It is only by voluntary exercise, gradually and systematically increased, that a patient suffering from cardiac insufficiency can be brought to a state in which he may be said to enjoy health, and in which he is comparatively safe from the extension of the pathological condition under which he is laboring.
    That exercise is the only means by which a muscle can be strengthened is a principle which 'applies to the heart as well as to every other muscle of the body.

570
    Massage for Palpitation of the Heart. - As palpitation and other forms of functional disease of the heart are, in the majority of cases, due to a disturbance of the sympathetic nerve arising from some disorder of the abdominal viscera, special attention should be given to abdominal massage in this class of cases. Palpitation may arise from dilatation of the stomach and resulting indigestion, or from the dragging upon the abdominal sympathetic, due to prolapse of the stomach and bowels, a floating kidney, a prolapsed liver, or a dislocated spleen. Care should be taken to see that each viscus is in its proper position, replacement being performed by the methods previously described, when necessary. Lifting the abdominal contents is especially important, and in cases of dilatation of the stomach massage of the stomach must be applied in such a manner; as to empty the organ of its fermenting and decomposing contents. In some instances, lavage of the stomach is essential as a preliminary measure whereby the disturbing poisonous substances may be removed. Massage of the heart (506-509) is also useful as a means of assisting the heart to acquire its normal rhythm. Massage of the stomach (451, 452) and replacement of the viscera (439-450) should be employed at least twice a day. In case the viscera are prolapsed, an abdominal bandage must be worn, being carefully applied after the viscera have been replaced. General massage is required daily.

571
    Special Exercises to be Employed with Massage. - Every masseur or masseuse ought to be skilled in gymnastics, as some of the morbid conditions which most urgently require the employment of massage are the result of deficient exercise and incorrect positions in standing and sitting.  Weakness of the muscles of the trunk is the principal cause of prolapse of the abdominal and pelvic organs and of deformities of the spine, and is either directly or indirectly the cause of a great variety of functional disorders of the abdominal and pelvic organs, as well as local and general nervous maladies for which massage is frequently prescribed.

572
    Massage alone is not sufficient to effect a permanent cure in these cases, for the reason that it does not remove the original cause. It is only capable of palliating or temporarily removing the consequences, and not the cause. It is necessarily of great importance that gymnastics should be combined with massage. I constantly employ manual Swedish movements, gymnastics with apparatus, Swedish educational gymnastics, and various outdoor exercises, such as bicycle riding, horseback riding, rowing, etc., as necessary complements of massage.
 

BODILY SYMMETRY AND CORRECT POISE.

573
    The trained manipulator should understand the importance of symmetrical development and the maintenance of correct poise when the body is in the erect position. Not a few of the maladies for which massage is frequently administered are quite as much the result of a wrong attitude assumed in sitting as of deficient muscular development. The sedentary life to which the majority of civilized men and women are subjected, and especially the sitting posture, which, as employed by civilized man is quite unnatural, are the immediate cause of various bodily deformities, especially contracted and rigid chest and prolapsed viscera, with wide_reaching mischiefs involving nearly every organ and structure of the body resulting, from these conditions. In enteroptosis, massage of the chest and abdomen, breathing exercises and daily replacement of' the stomach, bowels, liver, kidneys, or other displaced parts, will never effect a cure unless the patient is trained to sit correctly, carrying the chest high, so that the lungs may have an opportunity for full and free movement in inspiration. When the chest is lifted high, and maintained in this position, the effect is to draw the stomach, bowels, and other viscera up into position. With each inspiratory movement, the viscera are lifted up, and_the blood which is stagnating in their dilated vessels is sucked out by the diminished pressure within the chest, combined with compression of the viscera between the diaphragm and the abdominal walls.
    In plates XXXIII and XXXIV are shown some asymmetrical forms often encountered, together with natural and well-developed forms, which may serve as models. These are presented for the purpose of calling the attention of the reader to the importance of making a careful study of the conformation of the body in each patient, carefully seeking out deviations from the normal, and calling the patient's attention to, these defects, and assisting him to correct them by massage, manual Swedish movements, and such other measures as may be required.
    Every patient should be trained in correct sitting. It is especially important that the patient should be made to appreciate what is a correct sitting attitude. This may be accomplished by the following simple method:

574
    Figures 1 to 5 (Plate A) illustrate a very simple method of acquiring a healthful poise. Figure 1 shows a lady sitting in the position commonly assumed in the ordinary chair. The proper sitting poise is shown in Figure 2. By a careful study of these two figures, the difference in position maintained will be readily apparent. In Figure 1 the center of the back rests against the back of the chair, the chin drops forward,.the chest is flattened, the stomach and bowels depressed, and all the muscles of the trunk relaxed. In Figure 2 the hips and shoulders touch the back of the chair, while the center portion of the back is not in contact with the chair back. The chest is held well up, the chin drawn in, the abdominal muscles and all the muscles of the trunk are contracted, and the stomach, bowels, and other organs are thus held in proper place. The position shown in Figure 1 is transformed into the correct position of Figure 2. First, the hands are placed upon the hips, as shown in Figure 3. The head is thrown backward, so that the eyes look up toward the ceiling a little more than is shown in Figure 3. The body is then bent forward, as shown in Figure 4, the head being carried well backward, while vigorous pressure is made on the back with the thumbs. The purpose of the pressure with the thumbs is to cause firm contraction of the muscles of the back. This brings the chest forward, and corrects the posterior curve of the back, which is acquired by the habit of sitting in a relaxed position, as shown in Figure 1. While making firm pressure with the thumbs, the body is raised to the correct position shown in Figure 5. The pressure with the thumbs prevents relaxation of the muscles of the trunk while the body is being raised to position. While holding the body in correct position, the hands are removed from the hips, the shoulders allowed to rest against the back of the chair, the muscles of the trunk still remaining in forcible action, and thus the position shown in Figure 2 is acquired.

575
    The ordinary rocking chair is a recruiting agent for the undertaker. It is rare indeed to find a chair of any sort which is constructed in such a manner as to encourage a correct sitting poise. After studying this question for more than twenty_five years, the writer has had constructed a chair which he believes to embody the necessary principles for securing a correct sitting poise. The special features of this chair are a seat somewhat strongly inclined backward, a back curved slightly for ward at the bottom and inclining backward considerably more than that of the ordinary chair. The effect of this construction is to encourage the occupant to sit well back in the chair, while the head is, by the inclination of the back, carried backward to a point which necessitates the action of the anterior muscles of the neck in supporting it. This has the effect to make an upward pull upon the upper anterior part of the chest, thus encouraging chest expansion and deep respiration. This will be readily seen in the accompanying cuts (Plates A and B), which show the effect of the ordinary chair and that of the author's physiological chair. Rocking chairs constructed upon this plan are not only, comfortable, but wholly unobjectionable.
    The ordinary chair can be greatly improved by cutting off the back legs half an inch or an inch and fastening a properly shaped cushion to the back of the chair, two or three inches above the seat.

576
    When the internal organs are crowded out of place, various evils result. They become abnormally filled with blood, and their functions are variously disturbed. The stomach, for ex ample, can not properly discharge its contents into the intestines; the food is too long retained in the stomach, fermentation takes place, indigestion results. The fermenting and decomposing food passed into the intestines, produces disease there, and the abnormal liberation of gas distends the intestines, and constipation, hemorrhoids, intestinal catarrh, and other disorders are the consequence. The poisons generated by the long delay of the decomposed foods in the stomach and colon are carried to the liver and kidneys, and these organs likewise become disturbed. Other parts besides the liver and kidneys suffer. The brain becomes irritated. Neuralgia, confusion of thought, mental depression, nervous headache, backache, and general vital depression, are common consequences. The backache from which a large proportion of women, and many men, suffer, may be attributed, in many cases, to prolapse of the internal organs, due to a wrong position in sitting. Constipation and the numerous evil consequences which result from this condition, including anemia, neurasthenia, or nervous prostration, autointoxication, rectal ulcers displacement of the pelvic organs, ovarian and uterine congestion, and other pelvic disorders, are only a few of the morbid conditions which are a result of a relaxed sitting position.
The action of the lungs is also interfered with. Full and free respiration is impossible so long as the chest is depressed. The forward droop of the shoulders interferes with the raising of the ribs and proper expansion of the chest cavity. The constant relaxation of the abdominal muscles weakens that important muscle, the diaphragm, by removing the normal resistance against which it operates. The weakness of the abdominal muscles results in a corresponding weakness of the muscles of the back, so that the individual loses the ability to hold the trunk erect, even for a short time, without great weariness and inconvenience.
    Nearly all persons whose occupations require them to retain for considerable periods the sitting posture, suffer from these evil consequences; hence most women are found to be suffering from prolapse of the internal organs. The stomach and bowels are nearly always found depressed in women of twenty years and upward, the downward displacement varying from two to si x inches, or more. It is rare indeed to find a woman twenty-five years of age or over who has not serious displacement of important organs. Movable or floating kidneys and prolapsed stomach are exceedingly common, as well as displacement of the uterus and ovaries, from which so many civilized women suffer. Both men and women suffer from hernia, backache, neurasthenia, nervous dyspepsia, and bladder troubles, as the result of an unnatural sitting position.
    A correct poise in standing and walking is almost as important as in sitting. Drooping shoulders and forward carriage of the hips, are perhaps the worse faults. A correct standing poise may be easily acquired by the help of a very simple exercise when once the correct position is understood.

577
    Figures 6 and 7 show incorrect and correct standing positions. The correct standing position may be readily found by a simple exercise, taken by aid of the edge of a door, or a perpendicular wall. In Figure, 6 the person is shown standing with the usual incorrect poise against the edge of a door. Figures 8, 9 and 10 show how the correct standing position is obtained. Standing with the heels, hips, head, and shoulders against the edge of the door, the head is thrown backward until the chest is lifted forward, as shown in Figure 9, the heels and hips being held against the edge of the door. The hands are now put upon the hips, as shown in Figure 3. With the thumbs backward, a firm pressure is made with the ends of the thumbs. This contracts the muscles of the back so that when ,the head is thrown forward, the position shown in Figure 10 is found. Holding the muscles of the trunk forcibly contracted, the arms are allowed to drop by the side, and stepping free from the door, the excellent standing position shown in Figure 7 is acquired.

578
    Exercises Correcting Poise, to be Taken in Connection with Massage. - The author has found the following series of exercises of special value:

579
    Series A. - With the patient lying upon the face, the fore head resting upon the hands, placed one above the other, take the following exercises:
    1. Head raising backward four times.
    2. Leg raising, leg and foot extended , each four times.
    3. Leg raising, both together four times.
    4. Head and leg raising (Fig. 113), each leg two to four times.
    5. Head and legs raising, both legs together, two to four times.

580
    Series B. - Repeat the above exercises while lying upon back (Fig. 114).

581
    Series C. - Patient lying upon back, with the heels drawn up to the body.
    1. Hips raising (Fig. 82), two to eight times. The hips should be raised until the trunk and thighs are in line from shoulders to knees.
    2. Knees separating (Fig. 71). The knees should be separated as widely as possible. Repeat four to eight times.
    3. Hips-raising and knees-separating movements, thus: Separate the knees well, raise the hips, hold a few seconds, then bring the knees together while lowering the hips.
    The exercises of this series are especially designed to develop those muscles which tilt the pelvis backward, thus increasing the obliquity of the pelvis, a matter of much consequence in relation to correct standing, and also with reference to uterine displacements.

582
    Series D. - 1. Fill the lungs, raising the chest as high as possible. Hold chest high, while breathing out, expelling the air by strong contraction of the abdominal muscles. This raises the viscera and empties them of blood. Alternate with full breathing. The effect of this exercise is increased by placing the hands upon the hips with the thumbs and the elbows carried back as far as possible. Firm pressure should be made with the thumbs while breathing out. This prevents lowering of the chest.
    2. Empty lungs. Close glottis, and raise chest, without admitting air. Repeat, alternating with full breathing
    3. Sitting on the edge of an ordinary chair, place the hands upon the hips, as directed above, raise the chest high, and execute a swinging movement of the body, lifting the feet from the floor each time the trunk moves backward. The breath should be drawn in while the trunk moves forward. Sway the trunk backward and raise the knees while holding the breath. Let the breath escape just at the end of' the backward movement, and fill the lungs while bending forward. This rocking exercise should betaken several times daily, from twenty-five to fifty movements being executed each time. It is an excellent means of strengthening the abdominal muscles and training them to hold the viscera in position.
    4. Walking on tiptoe with the chest carried high, breathing wholly by use of the diaphragm and the abdominal muscles, is a capital exercise for strengthening the muscles of the trunk, especially those of the abdominal region.
    5. Breathing while standing against the wall with the heels, hips, shoulders, and head touching the wall, the chest being held as high as possible, is a very excellent means indeed of developing the diaphragm and the abdominal muscles.