Massage

MASSAGE, methodical mechanical impact on the surface of a patient's body, consisting of a series of techniques described below. - Anatomical and physiological rationale. The methodology of massage must be based on knowledge of the conditions of lymph circulation. The movement of lymph in tissues occurs under the influence of active and passive muscle movements, the displacement of tissues themselves due to their elasticity, and also under the influence of respiratory movements. The flow of lymph through the body is extremely slow (about 4 mm per second). If we assume the amount of lymph in the body to be equal to the amount of blood, all the lymph will pass through the thoracic duct only 6 times a day, whereas a complete circulation of the blood occurs within ¹/₂ minute. The slow circulation of lymph in tissues occurs because the entire mass of lymph, which is enclosed in the peripheral network and in internal organs, must pass through the narrow lumen of the thoracic duct. No small obstacle to the free flow of lymph is also presented by the lymph glands encountered on its path. One of the ways by which the flow of lymph in lymph vessels can be enhanced is massage. The effect of massage on lymph movement was proved by the experiments of Lassar and Mosengeil. Lassar inserted a glass tube into one of the large lymph vessels of a dog's thigh and measured the amount of outflowing lymph during rest and during massage. While at rest the lymph flowed out extremely slowly, in separate drops, during massage it began to flow in a stream. Mosengeil injected diluted India ink into several joints of a rabbit's limb and massaged one limb while leaving the other at rest for control. Upon autopsy, no ink was found in the massaged joints, but instead Mosengeil found abundant deposits of it in the connective tissue and central vessels. The unmassaged limbs presented no such changes. Technique and physiological action of massage techniques. The technique of massage consists of many individual manipulations, which can nevertheless be reduced, according to Metzger, to five main techniques: 1) stroking (effleurage), 2) friction, 3) kneading (pétrissage), 4) tapotement, 5) vibration. Stroking is performed in the direction of the course of lymph vessels (Figs. 1–3). Depending on the size and shape of the massaged part of the body, a flat or bent palm, the palmar surface of the thumbs, or the ends of all fingers are used. In places of large musculature, if it is necessary to penetrate deeply into

Figure 1. Stroking (initial moment).

tissues between muscle bundles, the so-called comb-like technique (Kammgriff) is used: the hand is folded into a fist,

Figure 2. Stroking (2nd moment).

and stroking is performed with the dorsal surface of the fist—using the prominences formed corresponding to the interphalangeal joints

Figure 3. Stroking (final moment). (Fig. 4). - Massage is performed with one and sometimes two hands (Figs. 5–7). Movements are performed in one direction. The masseuse guides the hand to the overlying joint or the nearest group of glands. The pressure applied during stroking does not always have to be the same.

Figure 4. Stroking (comb-like technique).

In places where large lymph or venous trunks pass, it may increase. Mainly, it must of course be adjusted to the pathoanatomical changes in the given case. Stroking must be performed rhythmically and necessarily slowly, corresponding to the slow flow of lymph. Stroking is the most frequent and repetitive technique of massage, with which a massage session begins and ends. Stroking aims to empty capillaries and lymph vessels, accelerate the flow of lymph and blood, resp. an resorptive effect in edema and effusions. The physiological action of stroking is primarily manifested on the skin, which

Figure 5. Stroking with one hand. Figure 6. Stroking with two hands. Figure 7. Superficial pressure.

is freed from epidermis scales that clog its pores. At the same time, the excretory ducts of the sweat and sebaceous glands are also cleaned, whereby the blood circulation and secretory activity of the skin integument improve. During stroking, an increase in skin temperature is noted. Stroking has a significant effect on veins, lymph vessels, and nerve endings embedded in the skin. Friction consists in the skin or deep tissues being rubbed in a circular direction with the end of one (thumb) or several fingers. For deep impact, the hands are folded into a fist and, just as in stroking, the dorsal surface of the first phalangeal joints is used. This technique differs from stroking, firstly, in that a significantly greater pressure force is applied here, and secondly, friction can also be performed against the flow of lymph and blood. Friction is recommended to be combined with stroking, with one hand rubbing and the other stroking (Fig. 8). Friction aims to break down pathological accumulations in tissues, create appropriate conditions and make tissues more capable of absorption, and also restore normal tissue mobility in adhesions. Friction causes tissue hyperemia and an increased influx of nutrients. By rubbing tissues, their contractility is excited, elasticity is increased, and their overall tone is raised. Energetic friction along nerve trunks or at the sites of nerve endings causes a decrease in nerve excitability.

Figure 8. Stroking and friction. Kneading is a variation of friction. The difference from the latter is that the hand does not move over the skin here, but, in close contact with the surface, moves the deeply lying and accessible layers of tissues. The technique is performed in such a way that the desired area is grasped between the thumb and forefingers in a transverse direction, lifted, and squeezed or rolled, with one or both hands making a progressive movement (Fig. 9). In its character, this technique resembles the squeezing of a sponge soaked in liquid. As with stroking, it is necessary to observe rhythmicity and a slow tempo here. The movements, however, must be strong enough to squeeze the contents out of the tissues. As a rule, stroking is performed before and after kneading. On broad parts, on the back, where the muscle belly spreads out flat (Fig. 10), kneading is combined with rubbing

Figure 9. Stroking and kneading.

to facilitate grasping the muscle belly. Kneading aims to act primarily on muscle tissue in order to induce enhanced contraction of muscle fibers, increase the contractility of muscle tissue, and express lymph. In addition, kneading also has a depletive effect. By alternately compressing the muscle

Figure 11. Figure 10. Figure 10. Massage lines on the back: on the left, the direction of the long muscles, on the right, the broad ones. Fig. 11. Tapping (hacking). mass, we, so to speak, free it from its contents. Kneading should be considered as passive gymnastics for muscle fibers; its action promotes not only the strengthening, but also the regeneration of the muscle. Tapping consists of repeated blows (Fig. 11). A whole series of modifications are distinguished here: clapping, hacking, puncturing, depending on the form of folding the massaging hand—with the palm surface, the ulnar edge, the ends of bent fingers, etc. Clapping and hacking are performed on wide surfaces of the body (chest, back), puncturing—predominantly along the course of the nerves. This technique is performed with one or two hands. In massage practice, the art of performing the technique is often evaluated from the point of view of obtaining the loudest sound. A loud sound during tapping by no means testifies to the correct execution of this technique. In terms of physiological action, tapping is very similar to kneading: its purpose is an increased blood flow to the tissues and, consequently, a strengthening effect on them. The action of the tapping technique boils down to concussion, and its influence is not limited only to the underlying tissues, but can also extend far deep into the internal organs: the spinal cord, intestines, liver, heart. Vibration consists in transmitting shaking movements to the body, which must be performed uniformly, one after another (see below).-In medical practice, some single described technique is extremely rarely used. According to Dollinger, the techniques of massage, like individual tones of music, never sound alone for long, but pass one into another, merging into a chord. Hand in hand with massage techniques, active and passive movements must also be performed, with elements of active movement being introduced predominantly. General rules. The massaged surface must be completely bared, muscles and joints must be relaxed (see below). The most convenient time for a massage session is the morning hours. Massage should be performed no earlier than 2-3 hours after a meal. The duration of a local massage session ranges from 2-5 minutes (selective massage of individual muscles) to 20 minutes (general segmental massage), the duration of a general massage (of the whole body)—up to 30-45 minutes. The determining factor is the sensitivity of the patient's tissues, the nature of the disease, the age of the patient, and finally the size of the massaged surface. The frequency of massage sessions can be from 1 to 3 times a day; repeated sessions are indicated for tissue nutrition disorders from inactivity or for severe neuralgic pains, where it is necessary to maintain the analgesic effect. Cleanliness of the air, optimal temperature, rational lighting of the room are the basic prerequisites for massage. The normal air temperature during massage should be considered 14°. Before massage, the skin must be washed thoroughly with warm water and soap or, even better, wiped with alcohol or ether. The latter circumstance is very important, because according to the studies of Makhnov and Babes, rubbing can cause bacteria to penetrate through the skin into the lymphatic pathways. On the same basis, to avoid the transfer of various skin diseases from one patient to another, the masseur is obliged to carefully wash their hands before each new massage, trim their nails, i.e., carefully observe the hygiene of their hands. One must be wary of massaging with great force against the hair, because in a few days the skin can become covered with pustules due to severe irritation. Massage should, if possible, not cause painful, sharp sensations. There should be no blue and purple spots (bruises) left on the skin after massage.-Position of the masseur and the patient during massage. Relaxation of muscles, firm support, stable balance are those basic principles upon which the position of the patient and the masseur during massage must be built. The tasks of all this are, on the one hand, to ensure maximum conservation of strength in the masseur, and on the other, to cause a minimum of tension in the muscles, ligamentous apparatus, and other tissues in the patient. The main position of the patient during massage should be considered the position on the back. If massage of the patient in a sitting position is permitted, the back of the chair must be wide enough to provide sufficient support for the soft parts of the body. Requirements for the masseur. They must possess knowledge of massage practice, a healthy heart, lungs, and in particular—be able to breathe correctly. The latter requirement is especially important for them because heavy muscular work, a frequently bent back position, shifted shoulders, variable work pace—all this creates unfavorable conditions for free, correct breathing, causing a violation of gas exchange in the lungs. The works of Demeny and others show that with a bent position of the spine, the intercostal spaces collapse, and shifted shoulders reduce the respiratory excursion of the chest, the result of which is insufficient ventilation of the lungs. The masseur must avoid these harmful factors, not overwork themselves with prolonged massage, and if possible keep the spine straightened during the massage. For the same reasons, the masseur must not talk during the massage. Frequent rest (a pause) for the masseur is a mandatory condition in their work. The masseur must maintain the most convenient position possible, causing a minimum of static expenditures in themselves to protect themselves from rapid fatigue. They should predominantly massage while sitting. Sitting on a stool or a piano stool is strictly not allowed. When sitting on a chair without a back, tension of the abdominal and back muscles occurs, and the calf muscles become especially fatigued, all the more so when the hands have to perform intense, prolonged muscular work. The chair must be very stable and sufficiently high. One should not tuck up their legs or dangle them in the air, because this quickly causes fatigue and also increases the synergistic contraction of distant muscle groups. If sometimes the masseur has to perform massage standing, then for the purpose of conserving strength, an asymmetrical position is recommended (support on one leg, the other brought forward) with a wide area of plantar support. When the hands are working, the masseur's torso must not make strong swinging movements, and their muscles must be relaxed and unstrained so as not to cause unnecessary expenditure of strength. The correct technique of massage work largely depends on the ability to control one's neuromuscular apparatus, for which the masseist needs to have a well-developed muscle sense. Lubricating substances during massage. As a rule, lubricating substances (lanolin, lard, boric vaseline) should be used when it is desired to act on deeper layers of tissue. If it is desired to cause a rush of blood to the skin by massage or to produce some mechanical irritation of the integument, a dry massage should be performed. Lubricating the skin with fatty substances does not facilitate, but rather hinders the performance of certain massage techniques. Kneading, for example, is much better performed with dry skin than with grease-lubricated skin. Boric vaseline should be considered the best lubricating substance. The amount of fatty substance should not be large, because friction between the skin and the hand is reduced and the effect of massage is almost lost. In addition, the sense of touch, which is so necessary for the masseur, is blunted. As lubricants for massage, sulfur ether and alcohol are also used, with the skin first being dried with alcohol and then treated with ether. Such a method of massage has a great advantage: the skin pores are open, the skin is cleaned, and the tendency to sweating is reduced. Indications and contraindications. Massage should be used in all cases when it is necessary to: 1) cause active hyperemia, increase the inflow of nutrients, improve metabolism in tissues; 2) achieve resorption in edema and exudates; 3) strengthen and increase muscle elasticity, activate the nervous system. - The most frequent field of application of massage is diseases of the locomotor apparatus: muscular atrophy, paresis, contractures, distortions, hemorrhages in joints, fractures, ingrown scars. In these cases, massage is one of the most important methods of kinesiotherapy. Muscular atrophy lasting for months due to inactivity after immovable bandages, immobilization with the help of massage disappears in a few weeks. In a short time, hemorrhage in the joint is also absorbed, and the formation of connective tissue adhesions leading to joint ankylosis is prevented. Under the influence of massage, the healing of granulating wounds is accelerated (Zabludovsky, Mysz). No less favorable an effect of massage is seen in the formation of bone callus. Lucas-Championnière recommended the systematic early (on the first or second day after trauma) use of massage in the treatment of fractures. In fractures, massage maintains the normal tone and nutrition of muscles and skin, revives blood circulation, especially in young bone callus, which is poor in blood vessels, and also acts in an analgesic manner. By enhancing the inflow of arterial blood, massage promotes the regeneration and enhanced growth of bone callus.

According to Gurevich's observations, bone fractures heal twice as fast under massage treatment as without it. During the first weeks, massage of the fracture site must be avoided, because under normal healing conditions this leads to excessive callus formation. The purpose of massage in diseases of the nervous system is to maintain the nutrition and partly the function of paralyzed parts. When muscular imbalance occurs as a result of weakness or partial paresis of individual muscles, it is necessary during massage to adhere to the selective principle—namely, strengthening the weaker muscle or a whole group of them while not forgetting the antagonists. For example, in pes equinovarus paralyticus, massage should primarily concern the group of surviving extensors of the foot (tibialis anterior muscle or extensor digitorum communis muscle); as for the flexor group (gastrocnemius muscle), the latter is massaged less energetically. In neuralgias, massage of painful points leads to the blunting of hypersensitivity. Massage exerts a major therapeutic influence in diseases of internal organs. Massage enhances intestinal peristalsis, improves the blood circulation of abdominal organs, etc. Massage produces an excellent therapeutic effect in many gynecological diseases (see below). Massage is contraindicated in all acute febrile diseases, in malignant tumors (cancer, sarcoma), in suppurative processes, and the like. Vibrational massage (seismotherapy) consists of methodical oscillatory movements produced by hand or with the help of an apparatus for therapeutic or hygienic purposes. Physiological action of vibrational massage. The influence of vibrational massage on the organism has been studied for a long time. As early as 1878, Mortimer Granville began his experiments on studying the influence of vibration on the alleviation of pain. Using his "percuteur" (an instrument for mechanical massage), Granville tried to introduce dissonance into the rhythm of painful vibrations and thereby change the character of pain. According to Granville's observations, at a certain rhythm of vibrations, a decrease in the sensitivity of nerve trunks is obtained, as well as a sharp reduction in pain. In 1880, Maggiorani, and then Vigoureux, reported successful results from using vibration in the treatment of muscular spasm in hysteria. Indications of a similar therapeutic success in treating vibrations for hemicrania and dizziness are found in Gilles de la Tourette. For the treatment of this group of diseases, he used a vibrational helmet producing up to 100 movements per second. The action of vibration on muscles was studied by Bum, Zander, Th. Brandt, and others. According to these authors, vibration causes strong contraction of muscle fibers and increases tone. The influence of vibration on the heart muscle has been traced by Heitler, Hasebroek, and Garnault. According to their observations, under the influence of vibration, there is an increase in the tone of the heart muscle, a decrease in cardiac dullness, and the pulse slows down and becomes fuller and stronger. Nebel noted the disappearance of arrhythmia. The heart rate decreased by 5–8 per minute in healthy individuals and by 20–40 in patients suffering from tachycardia. There are numerous works on the influence of vibration on the nervous system. According to these studies, the action of vibration on the nervous system is closely related to the degree of excitability of the nerves subjected to the action of vibrational massage; at the same time, weaker vibrations cause excitation of non-functioning nerves (paresis, paralysis) and, conversely, comparatively strong vibrations lead to a decrease in nerve excitability (neuralgias, convulsions). Such mechanical irritations of vasomotor, sensory, and mixed nerves cause dilation of blood pathways (according to studies by Istomov, Tarkhanov, Grützner, Heidenhain). According to Kleen, such hyperemia enhances tissue metabolism and also promotes the resorption of pathological exudates. Colombo's experiments proved the major influence of vibrational massage on internal secretion. According to the same author's observations, the secretory activity of the gastric mucosa 15 minutes after massage increases significantly. The activity of the gallbladder likewise increases, with an increase in the content of bile, cholesterol, and bile acid salts. Upon concussion of the kidneys, diuresis increases significantly after just 10 minutes, the urine becomes lighter, and its specific gravity decreases. According to Mackenzie, vibrational massage in the submaxillary region can cause increased salivation. According to the same author's observations, vibrations in the epigastric region arouse a feeling of hunger in the patient. The influence of general vibration on the organism has been studied by many authors, whose observations established that in a number of healthy individuals, after 15–20 minutes, pupil dilation occurs, along with a decrease and slowing of the pulse, slowing of respiration, a drop in temperature, an increase in blood pressure, and a decrease in susceptibility to pain; by the end of the session, drowsiness sets in for many. Technique of vibrational massage. According to Colombo, the following techniques of vibrational massage must be distinguished: 1) vibration (vibratio), manual and mechanical, 2) concussion (Erschütterung), 3) picking-pinching (Harpengriff), 4) repulsion (propulsio), and 5) shaking (succussio). All these techniques of vibrational massage are based on the fact that the operator's hand, without leaving the body part subject to massage, imparts various oscillatory movements to it, starting from the weakest impulse—vibration, in which molecular oscillatory movements of tissues occur on the surface—and ending with a stronger impulse—concussion, pushing, and shaking up to the displacement of an entire organ. Most of the listed techniques of vibrational massage were developed by Ling and Georgi, while Colombo introduced repulsion and shaking into the practice of vibrational massage as special techniques. Of all the techniques of vibrational massage, the execution of actual vibration requires the greatest skill and proficiency (Figures 12 and 13). This technique is the most tiring. One should avoid tension in the auxiliary muscles of the hand and

Figure 12. Vibration

Figure 13. Vibration

with the finger.

with the finger; all muscle contractions should be localized primarily in the forearm area. The amplitude of movement in the wrist joint during vibratory movements should not exceed 4-5°; the elbow joint should be bent without excessive tension. The masseur, by tensing a large number of muscles, quickly exhausts their strength, losing in their fingers the sensitivity which is sometimes very necessary for obtaining gentle and light vibratory movements. Prolonged vibration (over 10 min.) soon causes the masseur sharp pain in the forearm muscles, which then spreads throughout the arm. As a result of frequent and prolonged sessions of vibration, a spasmodic contraction of the fingers often appears. All this served as an impetus to replace manual vibration with mechanical. The introduction of devices into massage practice has significantly facilitated and expanded the indications for the use of M. in many diseases. Thus, with the help of special devices, it became possible to easily and freely perform vibratory M. in cases where the execution of its individual techniques by hand is extremely tiring (prolonged vibration), or where the performance of manual vibratory M. is difficult due to anatomical-topographical conditions (M. at the exit of nerve trunks of the n. ischiadici, nn. supra- and infraorbitalis), or finally where vibratory M. is little or completely inaccessible to direct finger action (nasal cavity, ureters). The mechanical execution of M. played a major role also in changing the physiological effect on tissues. Depending on the force or frequency of the movements produced during vibratory M., it is possible to a greater or lesser extent to increase or even change as a whole the physiological action of these techniques on tissues. Thus, slow vibrations, up to several hundred per minute, have a purely mechanical effect, fast ones; up to several thousand per minute, act like a strong faradic current (Breitman). Finally, with the help of special regulatory mechanisms that are present in massage devices, it became possible to a large extent to regulate the speed and force of individual massage techniques, sparing the patient and not tiring the working physician. Taking into account all the merits and advantages of this new kinesiotherapeutic method, it should nevertheless be emphasized that M. with apparatuses by no means should replace manual M., but should supplement it, deepening and clarifying the action of individual techniques on the tissues and organs of our body. Systems of apparatuses for vibratory massage and principles of their construction. The prototype of an apparatus replacing manual M. is the muscle-+-! t e l e r Klemm: rubber elastic, hollow inside sticks, connected at one end with a rubber handle. These sticks are of three kinds of length and thickness. With the help of this apparatus, tapping and pounding can be applied. To this group of devices should also be included various massage rollers, handpieces in the form of a ball, button, etc. (fig. 15), still used in the practice of cosmetic vibratory M. With the development of technology, these devices (vibratodes) underwent significant changes and improvements and at present have reached a very large number. In figure 16 various

Figure 14.

Figure 15. forms of vibratodes used in vibratory M. In order to make the vibration gentler, sponge rubber is attached to the surface of the vibratodes. Apparatuses used in seismotherapy can be divided into two large groups: apparatuses for 1) local vibratory M.; 2) for general vibratory M. For local vibratory M., many different designs and types have been proposed, some of which had to be set in motion by feet, others by hands; with the development of technology, an electric motor was used to set in motion devices for vibratory massage. The electric motor is either directly connected to the handle (fig. 14) or mounted on a movable stand allowing the motor to turn in all directions. Of the more complex systems, set in motion by a dynamo machine and giving up to 8,000 vibrations per minute, mention should be made of the apparatuses for mechanical M. of Zander and Herz (Zander, Herz). Zander's apparatuses, built on the principle of a crankshaft_: are constructed for almost all

procedures of vibrational massage: shaking, rubbing, patting, etc. Vibrational massage is sometimes combined with electrization or heat, for which the vibrator is connected with an electrode device or equipped with a special thermophore. For general vibration, the vibrating chair or Hertz's vibrating bed are used as instruments. General rules: 1) the motor of the apparatus should not overheat during operation; 2) do not press the tip against the body so that the motor's action is impeded (such impeding, or even stopping of the motor, quickly leads to its damage); 3) avoid frequent and rapid switching from one speed to another; 4) do not bend the flexible shaft too sharply to avoid breaking it; 5) do not turn on the motor at full strength immediately; 6) gradually increase the number and intensity of vibrations (motor speed); 7) during massage, do not grip the handle of the apparatus tightly, as this leads to rapid muscle fatigue; 8) lubricate the apparatus frequently with machine oil. Indications and contraindications. The general indications for vibrational massage are almost the same as for manual massage. It should be added that the scope of application of vibrational massage is much wider than that of manual massage, as with this method it is possible to affect deep organs located in cavities, which were previously completely inaccessible to direct finger action. Seismotherapy is used with great therapeutic success in cases of pareses and paralyses, as well as in neuralgias and neuritis. Vibrational massage is fully indicated for stagnant liver, catarrhal jaundice, causing outflow - depletory action. The same can be said about stones in the kidney, gallbladder, provided there is no bleeding or acute inflammatory phenomena. Catarrhal and atonic conditions of the intestine, especially constipation (vibration of the solar plexus), respond excellently to vibrational massage. Finally, it is necessary to point out the excellent therapeutic effect of massage in various diseases of the larynx and nasopharyngeal space. In gynecological diseases, massage can act as a resorptive agent, as well as to tone the muscles of the uterus (prolapse, change in shape). Vibrational massage is contraindicated in all cases of suppurations, intoxications, aneurysm, phlebitis, malignant neoplasms, acute gonorrhea, etc. It is also absolutely contraindicated to massage the abdomen (stomach and intestines) in the presence of ulcerations and a tendency to bleeding. a. Verbov. Massage in gynecology. Gynecological massage as a therapeutic method was proposed and developed in 1868 not by a physician, but by Major Thure-Brandt of the Swedish service, who was engaged in gymnastics, particularly medical gymnastics; he made great efforts to develop this method and to draw the attention of physicians to it. In Russia, much was done by Professor D. O. Ott and his school to spread gynecological massage. The method has survived the period of enthusiasm and has been preserved within certain limits, occupying a definite place in the treatment of female diseases. For success in the application of massage, the first condition is experienced hands and good orientation during gynecological examination; the second condition, as with any method of treatment, is, besides accurate diagnosis, the establishment of indications; therefore, massage can only be applied by a physician or a specially trained person. Indications for gynecological massage are: incorrect positions of the uterus, deviations backward or to the sides, unfixed and fixed displacements and adhesions of the appendages, remnants of inflammatory infiltrates in the cellular tissue, peritoneum and appendages of the uterus, old hemorrhages, strands, scars and adhesions, stagnant processes in the pelvic organs, chronic inflammation of the uterine muscle in the initial stages, then poor involution of the postpartum uterus, and on the other hand, insufficient development of the uterus (aplasia) with amenorrhea and hyperinvolution. The effect of treatment consists in reducing stagnant phenomena in the blood and lymphatic systems, regulating blood circulation in the muscles and nervous system of the pelvic organs; under the influence of massage, blood supply is significantly improved, infiltrates, hemorrhages and strands are resorbed, mobility of the pelvic organs increases, their interrelationships and tissue nutrition are corrected. Contraindications are acute and subacute inflammatory processes in the pelvic organs, feverish cases and especially purulent accumulations, infectious diseases (general and local) of the pelvic organs, gonorrhea, tuberculosis, any suspicion of malignant neoplasms, presence and suspicion of pregnancy, especially ectopic. Disorders of the nervous system, increased sensitivity may also be contraindications to massage. The appearance of pain during or after massage should also prevent its further application. Technique. Gynecological massage is performed either on a special low bench (the doctor sits on a stool nearby), the foot end of which is raised to reduce tension of the abdominal muscles, with the patient's legs bent at the knee and hip joints, or on any table for gynecological examination, and then the doctor is positioned between the patient's thighs; the bladder and rectum must be emptied; two fingers of one hand are inserted into the vagina, the action of which is mainly to lift and fix the uterus (depending on the need, through one or the other fornix), but in general they remain almost motionless all the time to avoid the possibility of sexual arousal (avoid touching the area of the clitoris); the other, external, hand performs circular movements and rubs and strokes the organs raised by the internal hand and individual areas of tissue; the movements of this hand are made as gently as possible, but sometimes become quite energetic when it is necessary to break adhesions and separate different areas of organs; in some cases, the fingers of the internal hand are inserted into the rectum instead of a sleeve (in virgins or with a narrow sleeve), and sometimes one finger in a sleeve and the other in the rectum. As an auxiliary method in gynecological massage, massage of the abdominal coverings is used, in addition vibrational massage is applied, for which there is a whole assortment of tips of various types depending on the method and place of application of massage (external coverings, abdominal, lumbar muscles, vagina, rectum); these tips are set in motion by special machines similar to dental drills; the drive can be manual, foot or electric. In parallel and in addition to gynecological massage, treatment by the doctor with gymnastics, very carefully developed by the same Thure-Brandt, active and passive, which also gives good results, is very often applied.

l. Krivsky. M. in dermatology. The main goal pursued by the application of local M. in skin diseases is to create more favorable conditions for blood circulation, and to improve through this the nutrition of these areas of the body, which contributes to the more rapid reverse development and resolution of painful foci. With M. of a specific area of skin, the blood flow in the latter is accelerated, which eliminates stagnant phenomena and the often associated dilatation of skin vessels. In addition, M. accelerates the delivery of nutrients from lymphatic pathways to the skin and promotes the removal of waste products from the skin. Thus, the overall metabolism in the skin sharply increases, and where there is a hypertrophic process, a reverse development in the form of regressive metamorphosis may occur, while in atrophic processes, opposite phenomena can sometimes be expected. This explains why sometimes the same M. procedures give an equally favorable therapeutic effect in completely opposite pathological processes. Indications for M. are the following skin diseases: 1) "stagnant" hands of red or bluish-red color, often associated with profession (work in the cold, in water, chilling, etc.); however, such discoloration of the hands, especially in women, is also often encountered without visible external influences, and in these cases it is associated with disorders of the endocrine-vegetative nervous system, with vasomotor disorders, with disorders of the sexual sphere, etc., manifesting quite often in youth. Such changes in skin discoloration of the hands, sometimes accompanied by some thickening of the latter, serve as a quite favorable object for M. 2) Acne rosacea of the face, especially the nose. On the other hand, with faded pale skin caused by insufficient blood supply, the application of appropriate M. can sometimes also achieve favorable results: arterial circulation and nutrition of the facial skin improve, and the latter can acquire a more "fresh" healthy color. The therapeutic effect of local M. of the skin in all these cases is usually very limited, since almost all these skin discolorations are associated with the general condition of the body, with functional disorders of internal organs (gastrointestinal tract, nervous system, etc.). Therefore, local application of M. of the skin should be carried out only in combination with general treatment and a general strengthening regimen. In addition, frequent indications for the application of M. of the face are two opposite processes: on the one hand, flabby, wrinkled skin caused by sharp weight loss (disappearance of subcutaneous fat) after severe infectious diseases, mental experiences, etc., on the other hand-too tense shiny facial skin, with a pronounced puffiness, especially around the eyes, encountered in connection with general obesity as well as with a whole series of other causes (climacteric, frequently recurring erysipelas, dysfunction of the thyroid gland, alcoholism, etc.). M. of the face is also indicated in scar changes of the skin: with appropriate M. techniques in combination with injections of fibrinolysin and iontophoresis with KJ, it is sometimes possible to achieve softening, smoothing, and in some cases complete resolution of scars. The most common application of M. is found in the treatment of acne (comedo, acne vulgaris). Along with the usual types of M., here extrusion of acne and pustular acne are also used to empty their contents, which should also be considered as special M. techniques. Unfortunately, in this area there are frequent abuses by so-called masseuse-"cosmeticians", while M. for acne requires special caution, since inappropriate extrusions and manipulations can sometimes further worsen the process. Contraindications to M. of the skin. A general contraindication is various inflammatory processes of the skin, occurring acutely or showing a tendency to exacerbation; this also includes dermatoses accompanied by suppuration and standing in etiological connection with pus-forming cocci. There are also individual contraindications to M., caused by increased sensitivity of the skin to all kinds of mechanical irritations. Special caution is required in M. of seborrheic skin, which sometimes gives irritation in the form of redness, scaling, up to seborrheic eczema, sometimes very persistent. Along with mechanical irritations, chemical factors also play a role here; in these cases, vaseline and other fats used for M. should not be applied. Techniques in dermatology. One must distinguish between manual and instrumental M. Manual M. consists of a series of techniques, sufficiently well defined by their very names (see above). Various techniques of M. and schemes of direction of massage movements, proposed at one time, have now lost their significance and have mainly historical interest. At present, a M. session usually consists in alternating the above-mentioned techniques, with predominance of some over others according to different dermatoses and purposes of M. Thus, for example, in cases where it is necessary to eliminate swellings (puffiness) and tension of the skin in connection with a pronounced subcutaneous fat layer, such M. techniques as rubbing and stroking are necessary, while for flabby, folded and wrinkled skin, squeezing and kneading are mainly recommended. The latter group of techniques, proposed by Jaquet and Leroy (Jacquot, Leroy) in the form of so-called plastic M., has gained wide distribution and great practical significance due to their simplicity and therapeutic effect. In cases of stagnant skin, with manifestations of acne rosacea, plastic M. is applied in combination with stroking. Finally, in all cases, vibrational M. can be applied. All other M. techniques should be carried out only by an experienced masseur, avoiding various devices, cups, rollers, etc., which more often do harm than good. The skin is not equally sensitive to different M. techniques: deep kneading, alternating squeezing and patting, as well as vibratory movements irritate the skin itself to a lesser extent than stroking, rubbing, and superficial kneading. Therefore, the use of this kind of manipulation requires caution and preliminary testing of the degree of skin sensitivity. In stroking and rubbing, it is sometimes advisable to use a small amount of fat (pure American vaseline, almond oil, etc.), while in other techniques the use of fat is irrational. M. sessions should be conducted no less frequently than every other day, with a session duration of no more than 10-15 minutes.

s. Sladkovich.