General Massage*, during which the patient lies undressed in bed (and should always be massaged by some one of the same sex), comprises the greater part of the body, begins with the extremities, and on the whole goes from the periphery towards the centre. The patient lies on the back except while the back is being massaged, when he lies on his face. General massage is given by my pupils as follows : -

The masseur begins with the upper extremity, using his hands as follows : - With his opposite (e.g., left) hand he grasps the patient's (right) hand, and with the whole palmar surface of his other hand performs effleurage over the superficial veins of the front and radial side of the whole arm, from the wrist upwards, namely, over the cephalic, basilic, and median veins and their anastomoses (Figs. 3 and 4). After half a dozen such strokes he begins treatment of the forearm by compressing by deep effleurage with one (right) hand the muscles on the anterior surface, and then with the other (left) hand the muscles on the dorsal surface. Petrissage of the forearm follows, and, like all the manipulations, is repeated a few times. It is performed over the whole muscle mass; the masseur, holding his thumbs moderately abducted and the four fingers somewhat flexed, grasps the forearm between his two hands, one on each side (front and back), touching it with the palmar surface, with the radial surface of the forefinger, and with the palmar surface of the thumb (Figs. 15 and 16). He then kneads with small, smooth, circular movements, which by degrees, without the hands ever leaving the patient's skin, travel over the whole surface from the wrist to the elbow. In the tapotement which follows he gives light blows with the fist to the thicker muscles on the flexor aspect; to the thinner extensors he gives light blows on the dorsal aspect of the forearm with the dorsal surface of the four fingers of the open hand (see Fig. 21). The muscles of the forearm are then again compressed by effleurage as described above. This finishes the treatment of the forearm. Before going on to the treatment of the upper arm, effleurage over the whole arm may be repeated. He compresses the anterior muscle groups with one hand, and then with the other hand treats the posterior muscles in the same way. In the petrissage which follows he treats the anterior muscle groups by themselves and the posterior by themselves; he gets at the posterior muscles best by adducting the patient's upper arm in front of his chest (Fig. 17). He then gives tapotement (best with the fist) over both muscle groups, and again compresses them by effleurage. He strokes, kneads, claps, and strokes again the deltoid muscle by itself, and completes the treatment of the arm by effleurage over the whole.

* General massage has been used in the interests of health from time immemorial (especially with baths) by nearly all Oriental, as well as by several European races, and it is widely met with as a popular remedy, for example, in the islands of the Pacific. Medically it is perhaps most often used and with much benefit as a substitute for physical exercise when this is for any reason impossible. It plays an important part in the so-called Weir-Mitchell treatment. In dystrophies, "general weakness," and chlorosis it is also of value.

When both arms have been thus treated the masseur goes on to the lower extremities, grasps with his opposite (e.g., left) hand the patient's (right) foot, compresses with the thumb of his corresponding (right) hand the network of veins on the dorsal surface of the foot, and with a continuous movement strokes with the palm of the same hand over the veins of the calf and the popliteal vein, following the saphenous vein with the thumb (Fig. 1). When the masseur's hand in this continuous effleurage has reached the lower part of the femoral vein on the front of the thigh he then rotates this hand (without breaking off the effleurage which should go with one stroke over the whole limb) so that the thumb, which would otherwise be directed outwards on the front of the thigh, is now directed downwards towards the knee, and the other four fingers, which would • otherwise be directed inwards on the front of the thigh (towards the mid-line of the patient), are now directed outwards (Fig. 2). By thus changing the position of the hand, when the effleurage ends at the groin the hand comes near the external genital organs without discomfort.

Treatment of the leg begins and ends, like that of the forearm, arm, and thigh, with compression of the muscles, in which he lets the thumb of the corresponding hand go on the inner side of the calf muscles, while the four fingers encircle them. With the four fingers of the other hand he then compresses the peronei, letting the thumb act in the same way over tibialis anticus. The calf muscles must be kneaded by themselves and tibialis anticus by itself. For tapotement it is best to use the fists over the thick calf muscles.

In massage of the thigh one divides the muscles into four groups, and treats separately, one after the other, quadriceps femoris, the adductors, the inner flexors (semimembranosus and semitendinosus), and biceps by compressing them in the ordinary way, giving petrissage, hacking, and compressing again. The best way to place the patient and oneself for comfort and ease in reaching the part is too obvious to mention. After the special treatment of the thigh one again gives effleurage over the whole limb.

After finishing the treatment of the leg one next performs abdominal massage, or the so-called abdominal kneading, as above described (Figs. 25 - 28). It is a very important and effective part of general massage, and should not be omitted without special reason. It should occupy about fifteen minutes.

After abdominal kneading the patient should lie on the face for treatment of the back. Although the anatomical conditions are not particularly favourable for effleurage, to help the circulation we begin and end the treatment of the back with long, quick strokings, carrying both hands one on each side of the spine up and down over the whole surface between the neck and the hips. We knead the muscles over both sides of the whole back by performing small circular movements (Fig. 13) in which the patient's skin accompanies the hand of the masseur. One uses either the palmar surface of the whole hand, or its uppermost part ("heel" or base of hand). We then give a series of vibration-like manipulations with both hands at once, one on each side of and close to the spine, using the tips of the three middle fingers from the neck down to the lumbar region inclusive (Fig. 22), a treatment which has a very stimulating effect, but which, to be given well, needs some practice. Tapote-ment is then given in the form of back hacking from the upper part of the chest to the lower part of the lumbar region, the masseur's elbows being slightly supinated and the metacarpo-phalangeal joints slightly flexed (Fig. 20). Not only the ulnar border of the little finger comes in contact with the skin, but also its dorsal surface and that of the ring finger. Both these fingers, and especially the. little finger, are held somewhat abducted; many masseurs, zealous of technique, attach great importance to a certain "feathering "done with the abducted fingers, thinking that the power to do this and back hacking altogether offers a very good criterion for a clever masseur. Each side of the back is hacked separately, and then the spine itself in many cases.

Before and after back hacking one treats the muscles of the shoulder blade by themselves by giving effleurage, tapotement (with the finger tips), and again effleurage above and below the spine of the scapula.

The gluteal regions are next treated in the same way; but many patients dispense with this altogether. The treatment of the back ends as it began, with effleurage.

With women patients we leave the chest untouched; with men one can treat the pectoral muscles and subclavius by stroking, hacking, and repeated stroking.

If special indications exist for massage of front of neck, one may suitably end general massage with this.

In general massage all the manipulations are as a rule performed with moderate strength. It is important for patients, especially those who are having a long course of it, that it should be performed comfortably, or at least without discomfort.

If the masseur has quite dry hands, he generally uses no lubricant for general massage; if not, he uses either a lubricant or talc powder for effleurage.

General massage should take at least half an hour (preferably about an hour), demands little more than mere mechanical skill, and can in most cases be quite well performed by non-medical workers. The doctor in busy practice has seldom time to give it himself, and can entrust it to any trustworthy person of the same sex as the patient, after he has once give instructions for the special case.