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The RENAISSANCE, it must be admitted, added little to what the ancients knew respecting massage. I ought, however, to mention a curious tract by Paullini, which appeared about the end of the seventeenth century, and was entitled "Flagellum Salutis." The same subject was taken up a hundred years later (in 1795) by Meibomius, under the following head: "On the utility of flagellation in medicine, in the pleasures of marriage, and in the functions pertaining to the loins and kidneys." This title leaves no doubt as to the benefits which these two writers ascribed to flagellation in the treatment of certain affections, and in particular of frigidity.

As I have just told you, the practice of massage remained almost exclusively confined to the lower classes, being abandoned to the country quacks, and it is only within a few years that massage has obtained the right of domain in medicine. This movement of scientific renovation took place almost simultaneously in France, in Holland, and in Ger

many.

In France, in 1837, Martin represented to the Medical Society of Lyons the marvellous results which he had obtained from massage in the treatment of lame back and lumbago. Lebatard and Ellaume in 1860,* Rizet in 1862, showed the advantages which may be obtained from massage in sprains; but we must come down to the thesis of Estradère in 1863 before we find a comprehensive treatise on the effect of massage. Works on this subject have since multiplied, and I cannot even give you a full list of their titles, but I cannot refrain from indicating the great value which I ascribe to the brilliant work of Estradère, who was the first to put in clear light the physiological effects of massage, and the therapeutic benefits to be derived therefrom. Nevertheless, it is not France alone that derived all the benefits of this work. Holland has reaped advantages from it under the influence of Mezger and his pupils, and we see even now patients flocking from all parts of Europe to Mezger's clinic to essay the effects of massage under the direction of that celebrated masseur.

Mezger has written but little. The only treatise of his which we possess (and it is of very modest dimensions) was published in

Lebatard, Gaz. des Hôp., 1850; Ellaume, Gaz. des Hộp., 1859.

Rizet, "On the Treatment of Sprain by Massage." Paris, 1868.

Estradère, "On Massage: its History, its Manipulations, its Therapeutic Effects" (Thèse de Paris, 1863).

1868 at Amsterdam.§ He says in this work that it is his intention to devote himself particularly to those special applications of gymnastics which are called frictions, or, better still, massage. He adds that in 1853 he began at Amsterdam the treatment of sprains by this means; that little by little he improved his system, and that since 1861 he has occupied himself exclusively with massage. Mezger has gathered around him numerous pupils.

In Sweden, it is under the influence of Berghmann, of Helledag, and especially of Amström, that the method of Mezger has spread. In Russia, Berglind has been the pioneer in this direction. Lastly, in France, we owe to Norström, of Stockholm, a complete exposition of Mezger's method.

In Germany, it is under the influence of Rosbach, of Busch, and particularly of Schreiber** and of Reibmayr, that massage has taken a truly scientific development. The work of Schreiber has been translated into French, and more recently still into English; Reibmayr's has been translated into French and annotated by one of my pupils, who has made a specialty of massage.††

The methods of massage are divided (like those of gymnastics) into two great groups,massage without apparatus, and massage with apparatus. As for massage without apparatus, the only kind practised by Mezger and his followers, we have to distinguish four different manœuvres,-passes (effleurage), frictions, kneadings, and tappings.

Effleurage consists in light passes made with the hand. Sometimes it is the palm which is used, sometimes the fingers, or, more properly speaking, the pulps of the fingers or thumbs, or even the phalangeal joints. In the latter instance the fist is closed, and it is with the extremity of the articulations of the phalanges with the phalangettes that the skin of the patient is rubbed. The Germans give to this kind of massage the name of kammgriff (combing).

The frictions consist, as their name indicates, in making with the hands centripetal

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frictions, which are rendered rhythmical by alternating the movements of the hands.

Kneading is performed sometimes by pinching up a muscle, or by kneading it with the two hands, or, in another manner, by rolling with both hands the muscles of a region.

Tapping movements consist in tapping, slapping, or stroking certain regions. Slapping is made with the palmar surface of the hand, the skin being smitten more or less forcibly. Stroking is done with the inner border of the hand, with which the part on which one wishes to operate is percussed with greater or less force.

The apparatuses employed in massage are quite numerous, and I can only mention the principal. Sometimes the instrument is a simple affair, the flesh-brush or glove, the strigilis or flesh-scraper (raclette), which we find employed in remote antiquity, as is seen in one of the masterpieces of ancient statuary. Then come the more or less complex rollers (roulettes), with which of late years electricity has been conjoined, as in Butler's roller, Stein's cylinder. Then there are the wooden mallets, the ferules, the battledoors, whose number and whose form are variable, and whose application goes back to the most remote times. It is even probable that the old proverb, Se battre les flancs, etc. (about beating the loins), had an allusion originally to the custom of smiting the sides of the abdomen with a wooden paddle or a leather thong.

Among these latter instruments I must mention the percussor of Sarlandières, and the dorsal beater of Klemm, and the more complex muscle-percussor, which he has also recommended. I must also mention in passing the electric percussors, moved by electricity, and devised by Granville, which give an absolutely rhythmical series of percussions, and lastly, the more complicated apparatus which Zander has invented, and which also determines more or less prolonged percussions and strokes of considerable intensity.

these inunctions are of any great benefit, and reserves them for special cases only. Mezger favors the use in nearly all cases of inunctions with some fatty substance, to which he would add some essential oil of agreeable odor.

I shall not reproduce here the many formulæ of ointments and pomades employed by the different medicasters. Every professional bone-setter has his particular formula, and, what is a little curious, it is not to the manœuvres which he practises, but to the ointment which he uses, that he attributes the effect obtained. This reminds me of a little incident in my own experience, when I was reporter on secret remedies to the Academy of Medicine. I had my attention called to a certain popular ointment, which was said to cure herniæ. But this is the way that the proprietor ordered it to be used: the hernia must first be rubbed with the ointment, then it was enjoined that a well-fitting truss, sufficient to support the hernia, should be worn after the rubbing. It is so with all these queer pomades which are in use by the different professional "rubbers," the inunction has no efficacy unless the accompanying massage is well performed. For my part, I believe that the use of some fat or oil is advantageous in facilitating the movements and passes (glissements) of the hand, and I am in the habit of employing vaseline aromatized with an essential oil.

As to the question whether massage should be practised on the denuded skin, Schreiber recommends its performance through a thin flannel wrapper, and, in support of this, appeals to considerations of propriety and modesty. I think, however, with almost all authorities who have had to do with this subject, that massage ought to be practised on the naked body.

We come now to the physiological effects determined by massage. These pertain to the functions of the skin and muscles, to the circulation, nervous system, to absorption, and nutrition.

As for the cutaneous functions, energetic frictions rid the skin of the débris of epidermis by which it is encumbered. The ori

These apparatuses, however, are mostly abandoned, at least in France, and even by Mezger in Holland, and it remains for me now to discuss the two following points: first, the utility of fatty inunctions in conjunc-fices of the sudoriparous and sebaceous glands tion with the practice of massage; and, second, whether massage should be performed on the naked body, or through a certain amount of clothing.

Estradère, without attaching any great importance to ointments and inunctions, regards them, however, as having a certain utility. Schreiber, on the other hand, denies that

are cleared, and this facilitates the more regular and thorough performance of the circulatory functions, and respiration of the skin.

The action on the muscles is quite as marked, and by kneadings or strokings of the muscles we arouse and augment their contractility. Strike with the inner border of your hand the triceps cruralis, or the biceps,

and you will see produced on the parts of the muscle thus stroked a peculiar hard swelling, which results from its limited contraction. In certain pathological cases, where the adynamia is profound, as in typhoid fever, this cord-like swelling persists a long time. We have here a fact which well shows the local action of massage on muscular contractility.

Massage acts not only on the deep circulation, but also on the circulation of the muscles and skin. It is by kneadings and pressures that we influence the deep circulation, while it is by slappings and flagellations that we promote a greater activity of the cutaneous circulation, and all you have to do is to stroke a part with the open palm repeatedly to obtain over the parts thus smitten a redness of considerable intensity.

This enhanced activity imparted to the circulation entails an augmentation in its local and general temperature.

As for the local temperature, Mosengeil estimates the heat-rise by massage at 2° and even 3° C. Berné* places it at even a higher figure, and affirms that the rise in the local temperature may attain 5° C. The average, according to him, is 12° C.

The action on the nervous system is twofold, and this point claims our attention for a moment, for massage has been very much vaunted in the treatment of neuralgias. Massage, and, in particular, deep pressures and kneadings, produce traction and stretching of the nerve-filaments. Hégart has endeavored to demonstrate experimentally the elongation of nerves under the influence of the manœuvres of massage, and particularly of movements of flexion of the vertebral column.

Another action of massage on the nervous system is more difficult of explanation. I refer to the strange nervous effects produced by light rubbing (effleurement) of the skin, and which are described by some writers under the name of magnetic passes. You will find in the recent work of Baréty a description of the effects of these passes, which he calls neurization. This quite special effect of certain practices of massage, although still badly understood, must, nevertheless, be taken into account in estimating the results

*Berné, "Researches on the Modifications of the Local Temperature under the Influence of Massage" (Société Medico-Pratique, 1885).

Hégart, Wiener Med. Blätter, 1884.

Baréty, "Animal Magnetism studied under the Name of Neuric Force," etc. Paris, 1887.

which are obtained from these movements in the treatment of certain affections of the nervous system.

But probably the most important action of massage is that which it exercises on the absorption of certain effusions, whether hemorrhagic or inflammatory. Numerous experi

ments in physiology have been undertaken to explain this resolvent action.

For instance, Mosengeil, in injecting into the knee-joints of hares solutions of Chinese ink, has shown that when the joint is treated by massage, the Chinese ink which has been injected into the joints diffuses itself through the neighboring parts, and that this phenomenon is the more marked the longer the massage is continued. Moreover, Reibmayr and Höfinger have shown that when liquid is injected into the peritoneum of a hare, it is absorbed with greater rapidity if massage is practised. The following table, which I borrow from these experimenters, shows this quite peculiar local action of massage:

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In Sweden and in Germany, as you are aware, it is taught that the living cell is situated in a liquid atmosphere, to which is given the name of parenchymatous juice. It is by acting on this parenchymatous juice and on the lymph-spaces that, according to Loven, we are to explain the resolvent action of massage in inflammatory and periarticular affections.

Lastly, massage has an undoubted action on nutrition. It has, in fact, been demonstrated that the quantity of urea in the urine augments under the influence of general mas

sage.

Gopadze has even affirmed that the assimilation of azotized substances is rendered more active by massage. In a series of experiments made on four medical students who were sub

jected to a special dietary regimen, the nitrogen being estimated both in the aliments and in the dejections, a general massage of twentyfive minutes, made once a day, three hours after the principal meal, caused a diminution in the amount of azotized matters contained in the fæces. From this the experimenter concluded that the assimilation of azotized matters was augmented.

This increased activity imparted to the di

gestive and assimilative functions by massage has also been affirmed by a young Russian physician, Chpolinski, who, in his inaugural thesis, published last year, "On the Length of Time that Aliments ordinarily Sojourn in the Stomach," has shown that the massage of the stomachal region, practised for ten minutes at a time, will diminish the length of the sojourn of food in the stomach.

The first case on which he experimented was that of a medical student, in whom a meal consisting of five hundred grammes of meat was five hours and twenty-five minutes in completely disappearing from the stomach. The days when massage was performed the duration of gastric digestion was only four hours and thirty minutes.

In another subject, where a meal composed of two eggs and a gramme of salt required three hours and fifteen minutes for its disappearance from the stomach, massage reduced this period to two hours and forty-five minutes.

As you see, gentlemen, massage notably promotes the gastric digestion, or at least the passage of alimentary substances from the stomach into the intestine.

One of my pupils, Dr. Hirschberg, has taken up this question anew by some experiments which he has made in my laboratory, which have confirmed the data established by Chpolinski.

Taking for his basis a peculiar property which salol possesses of undergoing decomposition into salicylic acid only in an alkaline medium, Ewald had shown that we can utilize this reaction to ascertain the duration of the sojourn of aliments in the stomach. All you have to do is to test the urine for salicylic acid in individuals to whom salol has been given along with food; the more tardy the appearance of this acid, the longer will be the sojourn of the food in the stomach. In employing this reagent, Hirschberg shows that massage hastens this transformation, and that while in the ordinary state it takes two hours for salicylic acid to appear in the urine, forty minutes suffice after an abdominal massage.

These experiments have, moreover, brought to view a fact which physiologists who have taken up the subject of massage have touched lightly, and which at the same time seems to me to have capital importance in these applications of massotherapy: I refer to the augmentation of diuresis under the influence of

abdominal massage. All our patients on whom abdominal massage has been practised have testified to a notable augmentation in the

urine, which sometimes amounts to double the normal quantity, and this is an important point, to which I propose to return when we come to study the indications for massotherapy.

Now that you know the manœuvres of massage (which, in fact, are not at all difficult), and the physiological effects which may be expected therefrom, we may profitably take up the study of the therapeutic applications of massage.

II.

APPLICATIONS OF MASSOTHERAPY.

The applications of massage to therapeutics are numerous. We will, if you please, consider them under several heads, and will successively speak of massage in its applications to obstetrics, gynecology, surgery, and medicine.

1. The use of massage in obstetrics dates back from the most ancient times. Among all primitive peoples we find massage employed in the practice of midwifery. If you will refer to works written on the obstetrics of different nations (as for instance the familiar treatise of Corre), you will see that almost all the odd methods put in usage are only various forms of massage.

By massage four results are obtained,—(a) the contractions of the uterus are excited; (b) vicious positions are rectified; (c) the placenta is delivered by the process called expression (Credé's method); (d) hemorrhages are arrested. To-day all these manœuvres are well known, and give, as you know, excellent results.

Massage of the gravid uterus is made by circular passes over the abdomen. Under some circumstances bimanual massage is of great utility,-i.e., one hand is introduced into the uterine cavity, while the other endeavors by abdominal frictions to excite uterine contractions. This latter manœuvre is principally put in usage in cases of postpartum hemorrhages.

2. In gynæcology it is Norström who has shown himself the most ardent inculcator of massage, which one of his fellow-countrymen, Thure Brandt, a man who, by the way, had no knowledge of medicine, was the first to suggest for the cure of uterine affections. The practice of the Swedish empiric dates from 1868. Thure Brandt recommends three processes of massage, one of which he calls external massage, and which consists in rubbing and kneading the abdominal parietes, through which the operator seeks to plunge

his fingers deeply, and, if possible, into the by Paul Profanter, where massage applied to pelvic cavity.

The other process is called mixed massage. The patient is placed on her back, and the masseur, taking his position at her left, compresses the uterus with the right hand upon the index and middle finger of the left hand introduced into the vagina; in certain cases, even, the fingers are introduced into the rectum. But the process to which Thure Brandt gives the preference is that which he calls combined massage, and which I shall the rather call massage with four hands; and this is the way that this strange method is put in practice, demanding, as it does, two opera

tors:

One of the masseurs, taking his position between the legs of the patient, introduces the fingers of the left hand into the vagina and raises the uterus, while, with the right hand placed under the hips, he kneads the sacro-lumbalis muscles. The other masseur operates on the abdominal parietes, and associating and giving a rhythmical character to their manœuvres, the two practitioners devote themselves to rubbings, tractions, and kneadings of all sorts.

One cannot too strongly condemn such practices, and my pupil, Dr. Leon Petit, in his communication on "Massage of the Uterus," made to the Society of Practical Medicine,* has well shown how useless and how dangerous are such manoeuvres, which belong rather to the domain of onanism than to that of therapeutics. So, notwithstanding the facts cited by the advocates of uterine massage, and in particular by Reeves Jackson, of New York, and Norström, of Paris, I pray you never to employ such methods.

Besides all the moral drawbacks which result from this handling and rubbing of the genital parts, and of which I need say no more, there is a rule which is imperative in almost all uterine affections, viz., rest of the organ is indispensable. My master, Bernutz, has justly insisted on this fact, that in most uterine maladies it is rest of the organ and function which brings about the cure, and it is a violation of this rule to introduce the hand into the vagina, and thereby exercise pressures or frictions, which, however light they may be, tend to excite and congest the genitals. Therefore, notwithstanding the sixteen favorable observations recently published

* Leon Petit, "On Massage of the Uterus in Obstetrics and Gynecology" (Journal de Médecine de Paris, May 16, 1886).

the treatment of displacements and of prolapsus, as well as of uterine and periuterine engorgements, has resulted in cure, I persist in believing that this method has more of evil than of advantage in the treatment of these affections, and I pass now to the application of massage to surgery.

3. I shall be brief on these surgical appli cations, and shall concern myself particularly with the treatment of sprains by massage. I ought to remind you, however, that massage, heretofore reserved in surgery for the jointdiseases, has been applied the last few years to the treatment of fractures, and this has been done under the influence of Schode of Hamburg, of Menzel of Trieste, of Mezger and Tilanus of Amsterdam, and especially of Lucas-Championnière, who, in July, 1866, communicated to the Society of Surgery the successful results which had been obtained in fractures by massage. Berne, who was one of the first in France to recommend massage in the treatment of fractures, and whose writings are even anterior to those of Lucas-Championnière, considers fractures of the radius and of the fibula at their lower extremities, also those of the elbow and patella, as especially tributary to this method. He regards the application of a splint which can be easily removed at the moment of massage, as more useful than any permanent fixture, because presenting no impediment to the prompt return of the functions of the joint.

Quite recently, moreover, Prof. Masse of Bordeaux has taken up the subject again, and pointed out all the benefits derivable from massotherapy in counteracting the disastrous effects of immobilization as imposed by the retentive apparatuses hitherto applied in these cases.

The treatment of SPRAINS by massage has been attended with excellent results. First practised by the bone-setters, gray nuns, "sprain-blowers" (souffleurs d'entorses), etc., massage is to-day employed in the treatment of sprain by all surgeons, and the works of Ellaume, of Lebatard, of Mervy, of Estradère, of Rizet, etc., show us the importance of this method.

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