I now begin by permitting the patient to sit up in bed, then to feed herself, and next to sit up out of bed a few minutes at bedtime. In a week, she is desired to sit up fifteen minutes twice a day, and this is gradually increased until, at the end of six to twelve weeks, she rests on the bed only three to five hours daily. Even after she moves about and goes out, I insist for two months on absolute repose at least two or three hours daily, and this must be understood to mean seclusion as well as bodily quiet, free from the intrusion of household cares, visitors, or any form of emotion or excitement, pleasureable or otherwise. In cases of long-standing it may be desirable to continue this period of isolation and to order as well an hour's lying down after each meal for many months, in some such methodical way as is suggested in the schedule on page 64.

The use of a hammock is found by some people to be a very agreeable change from the bed during a part of the day.

The physician who discharges his patient when she rises from her bed after her two or three months' treatment, or who neglects to consider the moral and mental needs and aspects of each case, will find that many will relapse. Even when the patient has left the direct care of the doctor and returned to home and its avocations she will find help and comfort in the knowledge that she can apply to him if necessary, and it is well to hold some sort of relation by occasional visits or correspondence, however brief, for six months or a year after treatment has been completed.

CHAPTER VI.

Ma.s.sAGE.

How to deprive rest of its evils is the t.i.tle with which I might very well have labelled this chapter. I have pointed out what I mean by rest, how it hurts, and how it seems to help; and, as I believe that it is useful in most cases only if employed in conjunction with other means, the study of these becomes of the first importance.

The two aids which by degrees I learned to call upon with confidence to enable me to use rest without doing harm are ma.s.sage and electricity. We have first to deal with ma.s.sage, and I give some care to the description of details, because even now it is imperfectly understood in this country, and because I wish to emphasize some facts about it which are not well known, I think, on either side of the Atlantic.

Ma.s.sage in some form has long been in use in the East, and is well known as the _lommi-lommi_ of the slothful inhabitants of the Sandwich Islands. In j.a.pan it is reserved as an occupation for the blind, whose delicate sense of feeling might, I should think, very well fit them for this task. It is, however, in these countries less used in disease than as the luxury of the rich; nor can I find in the few books on the subject that it has been resorted to habitually as a tonic in Europe, or otherwise than as a means of treating local disorders.

It is many years since I first saw in this city general ma.s.sage used by a charlatan in a case of progressive paralysis. The temporary results he obtained were so remarkable that I began soon after to employ it in locomotor ataxia, in which it sometimes proved of signal value, and in other forms of spinal and local disease. At first I had to train nurses to use it, but I soon found that, although it was of some service to their patients, no one could use ma.s.sage well who was not continually engaged in doing it. Some men do it better than any woman; but I prefer, nevertheless, for obvious reasons, to reserve men for male patients, except that in cases where _strength_ is of moment, as in the forced movements and the very hard rubbing needed for old articular adhesions, in which force must be exercised without violence, it is usually impossible to secure the necessary power in a feminine manipulator.

A few years later I resorted to it in the first cases which I treated by rest, and I very soon found that I had in it an agent little understood and of singular utility.

It will be necessary, in pursuance of my plan, to describe as minutely as the limits of a chapter will allow how and why this means is employed. The process and order of what is known to the manipulator as "general ma.s.sage" follows.

After three or four days in bed have somewhat accustomed the patient to the general routine of treatment, a ma.s.seur or ma.s.seuse is set to work.

If any special care is needed,--the avoidance of manipulating one part or added attention to another, tender handling of a sensitive or timid patient,--these matters have been ordered in advance by the physician.

An hour midway between meals is chosen, and, the patient lying in bed between blankets, the manipulator begins, usually with the feet. A few rapid rubs of the whole foot and leg are given to start with; then the leg, except the foot and ankle, is covered up, and the operation commences upon the foot, of which the skin is picked up and rolled between the fingers, the whole foot receiving careful attention,--the toes are pulled, bent, and moved in every direction, the inter-osseous groups worked over with the thumbs and fingers or finger-tips, the larger muscles and subcutaneous tissues squeezed and kneaded, and last the whole ma.s.s of the foot rolled and pressed against the bones with both hands. A few rapid upward strokings with some force complete the treatment of the part, and the ankle is next dealt with. The joint is moved in every possible direction, slowly but firmly, the crevices between the articulating bones sought out and kneaded with the finger-tips, and the foot and ankle are then carefully covered. After the same rapid stroking upward of the leg with which it began has been repeated for the sake of the slight stimulation of the skin-vessels and nerves, the muscles of the leg are treated, first by friction of the more superficially placed ma.s.ses, then by careful deep kneading (_petrissage_) of the large muscles of the calf, twisting, pressing, and rolling them about the bone with one hand while the other supports the limb. In fat or heavily-muscled subjects it may be necessary to use both hands to get sufficient grasp of the muscles. The tibialis anticus and muscles of the outer side of the leg are operated upon by rolling them under the finger-tips and by pressing with the thumb while firmly pushing upward from the ankle to the knee. At brief intervals the manipulator seizes the limb in both hands and lightly runs the grasp upward, so as to favor the flow of the venous blood-currents, and then returns to the kneading of the muscles,--and each part is finished by light yet firm upward stroking, the hand returning downward more lightly, yet without breaking its contact with the skin.

Care must be taken as the different groups of muscles are treated that the leg is placed in the position which will most completely relax the ones to be operated upon. Any tension of muscles wholly defeats the effort of the ma.s.seur.

After completing the process upon both legs, the arm is next treated in the same manner, the hand receiving somewhat more detailed attention than the foot. Pains must be taken to reach the several groups of the forearm by operating from both sides of the arm. The ordinary manipulation of the shoulder can be accomplished with the patient lying down; but if special conditions, such as articular stiffening, call for unusual care or unusual force, it will be found best to treat the shoulder with the patient seated. The treatment of the arms is concluded with upward stroking (_effleurage_), as with the leg.

In the order usually pursued, the back is the next region treated. The patient lies p.r.o.ne, folding the arms under the head; a firm pillow is put under the epigastric region, so as to the better relax the back muscles, which are too tense when a person lies flat. Beginning from the occiput, both hands stroke firmly and rapidly downward and outward to the spines of the scapulae, at first lightly, then with increasing force.

Then the whole back is vigorously rubbed--scrubbed one might call it--with up-and-down strokes, as a preliminary application. The erector spinae ma.s.ses are treated by careful finger-tip kneading. Working from the spine outward to the axillary line, the muscles of the ribs are acted upon with flat-hand rubbing. The groups of the upper back and shoulder-blades are kneaded and squeezed, the arms being partly abducted so as to separate the shoulder-blades and allow the operator to reach the muscles underlying them. The lumbar regions receive their manipulation last. If it is desirable to give special attention or an extra share of manipulation to any part of the spinal region, this is done as the physician may have ordered, and the whole process is completed by downward friction over the spine, given vigorously and as rapidly as possible.

The chest is the next region to be handled, the patient turning from the p.r.o.ne to the supine position. In women the b.r.e.a.s.t.s are usually best left untouched unless special conditions demand their treatment.

The last and perhaps most important part of the process of general ma.s.sage is the rubbing of the abdomen. Particular care is needed to secure complete relaxation, as nervous patients and, still more, hysterical patients are apt to present extreme rigidity of the abdominal muscles. The head is raised by pillows, the knees are slightly flexed and sometimes supported by a folded pillow also. With this position the rigidity generally yields to gentle persistence, at any rate after a few treatments. If it does not do so, a lateral decubitus may be tried, a position in which the intestinal regions may be very thoroughly treated, and in which, if there be gastric dilatation, the stomach-walls can be best reached. Sweeping circular frictions about the navel as a centre begin the process; the abdominal walls are then kneaded and pinched[16] with one or both hands; deep, firm kneading of the whole belly with the heel of the hand follows, the movements following the course of the colon. Next, the fingers of one hand are all held together in a pyramidal fashion and thrust firmly and slowly into the abdomen, in ordinary cases both hands being used thus alternately, in fat or resisting abdomens one hand pressing upon and aiding the other, and travelling thus over the ascending, transverse, and descending colon.

To conclude, the whole belly is shaken by a rapid vibratory motion of the hands (to which is sometimes added succussion by slapping with the flat or cupped hand), and the whole process ends with quick, circular rubbing of the surface.

In cases of troublesome constipation or where other special indications exist, treatment of the abdomen may be much extended beyond the limits here suggested, and indeed it must be remembered that the process of "general ma.s.sage" as described is capable of a great variety of useful modification to meet individual needs, and is so modified daily by the careful physician and the watchful ma.s.seur. It would not be possible or desirable here to describe all the movements which a skilful rubber makes in his treatment, and I have only attempted a skeleton-statement.

It will perhaps be noticed by those familiar with the technique of ma.s.sage that nothing is here said about the use of the movements cla.s.sed under the general head of "tapotement," the tapping and slapping motions. They have no proper place in the treatment of cases of nervousness, and usually will serve only to irritate and annoy the patient, and often greatly to increase the nervous excitement. Their routine use or over-use const.i.tutes one of the defects of the system of ma.s.sage as usually practised by the Swedish operators; and when patients tell me, as many do, that "they cannot stand ma.s.sage," it is often found that the performance of a great deal of this useless and fretting manipulation has const.i.tuted a great part of the treatment, and that deep, thorough, quiet kneading can be perfectly borne.

A few precautions are necessary to observe. The grasping hand should carry the skin with it, not slip over the skin, as the drag thus put upon the hairs will, if daily repeated, cause troublesome boils. The use of a lubricant avoids this, and is a favorite device of unskilful manipulators. It also does away with much of the good effected by skin-friction, is uncleanly, very annoying to many patients, promotes an unsightly growth of hair, and should be avoided except where it is desired to rub into the system some oleaginous material. There are exceptional cases where a very dry, harsh skin or a tendency to excessive sweating during ma.s.sage makes the use of some unguent desirable. Cocoa-oil may be used, or what is perhaps more agreeable, lanolin softened to the consistency of very thick cream by the addition of oil of sweet almonds. As little as possible should be made to serve.

Too much care cannot be used to cover with stockings and warm wraps the parts after in turn they have been subjected to ma.s.sage. As to time, at first the ma.s.sage should last half an hour, but should be increased in a week to a full hour. I observe that Dr. Playfair has it used twice a day or more, and I have since had it so employed in some cases, letting the ma.s.seuse come before noon, and allowing the nurse to use it at night if it does not interfere with sleep, which is a matter to be tested solely by experiment. Commonly, one hour once daily suffices. I was at one time in the habit of suspending the use of both ma.s.sage and electricity during menstruation, because I found occasionally that these agents disturbed or checked the normal flow. Of late, however, I continue to employ both agents, but confine them to the limbs. I have met with rare cases in which almost any ma.s.sage gave rise to a uterine hemorrhage, and in which the utmost caution became necessary.

Women who have a sensitive abdominal surface or ovarian tenderness have of course to be handled with care, but in a few days a practised rubber will by degrees intrude upon the tender regions, and will end by kneading them with all desirable force. The same remarks apply to the spine when it is hurt by a touch; and it is very rare indeed to find persons whose irritable spots cannot at last be rubbed and kneaded to their permanent profit.

Sometimes when the patient is found to be much exhausted by ma.s.sage, it is well to give some stimulating concentrated food afterwards; occasionally it may be necessary both before and after. In this case it would be well to see that the rubbing was not being made too severe.

Very rarely I find a patient to whom all ma.s.sage is so disagreeable or produces such annoying nervousness as to make manipulation impossible; sometimes, though very rarely, ma.s.sage, especially frictional movements, causes s.e.xual excitement when applied in the neighborhood of the genital organs, or even on the b.u.t.tocks and lower spine, and this may occur in either sane or insane patients: if the rubber observe any signs of this, it will of course be best to avoid handling the areas which are thus sensitive.

Another complaint sometimes made is of chilliness after treatment, and especially of cold feet. If this is not lessened after a few days, the lower extremities may be rubbed last instead of first, or as is now and then useful, the whole order of ma.s.sage may be changed so as to begin with the abdomen, chest, and upper extremities and conclude with the back and legs.[17]

Beginning with half an hour and gradually increasing to about an hour (a little more for very large or very fat people,--a little less for the small or thin) the daily ma.s.sage is kept up through at least six weeks, and then if everything seems to be going along well, I direct the rubber or nurse to spend half of the hour in exercising the limbs as a preparation for walking. This is done after the Swedish plan, by making very slowly pa.s.sive and extreme extensions and flexions of the limbs for a few days, then a.s.sisted movements, next active una.s.sisted movements, and last active movements gently resisted by nurse or ma.s.seuse. When the patient is able to sit and stand, it is well to keep up and extend the number of these gentle gymnastic acts and to encourage the patient to make them habitual, or at least to keep them up for many months after the conclusion of treatment.[18]

At the seventh week ma.s.sage is used on alternate days, and is commonly laid aside when the patient gets up and begins to move about.

In 1877, several of the members of the staff of the Infirmary for Nervous Disease, and especially my colleague, Dr. Wharton Sinkler, obliged me by studying with care the influence of ma.s.sage on temperature, and some very interesting results were obtained. In general, when a highly hysterical person is rubbed, the legs are apt to grow cold under the stimulation, and if this continues to be complained of it is no very good omen of the ultimate success of the treatment. But usually in a few days a change takes place, and the limbs all grow warm when kneaded, as happens in most people from the beginning of the treatment.[19] The extremely low temperature of the limbs of children suffering with so-called essential paralysis is well known. I have frequently seen these strangely cold parts rise, under an hour's ma.s.sage, six to ten degrees F. In such small limbs, the long contact of a warm hand may account for at least a part of this notable rise in temperature. In adults this can hardly be looked upon as a cause of the rise of temperature produced by ma.s.sage, first, because the long exposure of large surfaces incident to the process is calculated to lessen whatever increase of heat the contact of the hand may cause, and secondly, because this rise is a very variable quant.i.ty, and because occasionally some other and less comprehensible factors actually induce a fall rather than a rise in the thermometer as a result of ma.s.sage.

In very nervous or hysterical women, ignorant of what the act of kneading may be expected to bring about, and especially in such as are thin and anaemic and have either a somewhat high or an unusually low normal temperature, we may find at first a slight fall of the thermometer, then a fairly constant rise, with some irregularities, and at last, as the health improves, a lessening effect or none at all.

The most notable rise is to be found in persons who, owing to some organic disease, have acquired liability to great changes of temperature.

It is impossible to observe the increase of heat which follows both ma.s.sage and electricity without inferring that these agents must for a time, like exercise and other tonics, increase the tissue-waste by the stimulus they cause of the general and interst.i.tial circulations, and by the direct influence they seem to have on the tissues themselves. I have sought to study this matter carefully by placing patients on a fixed and competent diet of milk alone, and by estimating the waste of tissues as shown in the secretions before and after the use of ma.s.sage. This study, although it was never completed in a satisfactory manner, would seem to show that ma.s.sage does not much alter the total elimination of the entire day, but causes a large and abrupt increase within three hours, followed by a compensatory decline.[20]

I add a number of tables, which very well ill.u.s.trate the facts above stated as to rise of temperature.

Mrs. J., at rest, on the usual diet. Manipulation at 11, daily:

Before Ma.s.sage. After Ma.s.sage.

100 100

100 100-1/5

99-2/5 99-4/5

99-4/5 100

99-2/5 100

100 100

99-4/5 100

99-4/5 100

Miss P., aet. 24, hysteria:

Before Ma.s.sage. After Ma.s.sage.

99-1/4 99-1/4

98-1/4 99

98-1/2 99