The relation of massage to the treatment of poisoning has for long been an open, but as yet an almost unexplored, field of discovery, which may be expected to be productive.

The physiological effect which we might expect to be useful is the mechanical stimulation of the nerves, and this has for long been used in the treatment of a collapsed or comatose condition, either in the form of tapotement with the flat hand, flicking with towels, beating with a rod, or "flagellation," either on the palm of the hand, or the sole of the foot, or over the whole body. General massage, as already described in this book, is important in the treatment of the sensory and motor symptoms in cases of chronic poisoning. In cases of motor disturbances muscle massage is of great importance. The local effect of effleurage on the circulation is made use of for the prevention of gangrene. Lastly, the effect of massage on the heart and circulation must not be overlooked. Abdominal kneading is especially valuable in this respect, and should be included in the treatment of most cases.

* "The Treatment of Rickets by Massage and Passive Movements." P. Silfverskjold Eira, 1880.

From this it may be seen that massage in cases of poisoning where the symptoms are a complex arising from the cerebrospinal and circulatory systems is usually "general" massage, varied according to the nature of the case.

The gymnastic exercises used in cases of poisoning are chiefly those which affect the heart and respiration.

The commonest forms of poisoning which one would expect to be benefited by massage and gymnastics are acute and chronic poisoning by the narcotics in common use, e.g., opium, morphia, cocaine, chloroform, chloral, sulphonal, trional, veronal, and alcohol, with other medicinal drugs such as aspirin, antipyrin, antifebrin, etc., acute poisoning by marsh gas, carbonic acid and coal gas, acute and chronic metal poisoning, poisoning by fungi, and snake bites.

Auto-intoxications arc important and numerous, especially in diabetes (from β-oxybutyric acid) and in Bright's disease (from urea). Sudden death has been known to occur from uraemic coma on the cessation of general massage in advanced chronic inflammation of the kidneys, just as death from diabetic coma may, as 1 have already pointed out, occur under the same conditions.

According to Barett, Buller. Levis and Meyers, and others, in cases of acute narcotic poisoning, as in advanced cases of alcoholism, stimulation of the nerves by flagellation plays an important part (see Schrieber, "Massage"). In addition general massage, respiratory movements, electricity, cold douches, and other means available must not be forgotten.

General massage is also of value in cases of chronic poisoning. The most common of these are alcoholism, cocainism, chloralism, and morphinism, and it is perhaps particularly in the last (simple, or complicated by any other isomeric poison) that massage is of most value. In any case, however early, it is quite useless to treat these terrible diseases outside the special asylums where the patient is under full control. This can only be secured in a special institution where he is under constant and trustworthy supervision. In breaking off the habit the daily dose is first reduced by half, and then diminished more slowly.* The patient frequently becomes so melancholic that every means is made use of to strengthen the heart and muscles and to improve the general condition. Especially during the time when he is confined to bed, which has its advantages, general massage, given by a firm reliable person, preferably two or three times a day, in my limited experience, does much good, and helps to some extent to shorten the terrible period of psychical and somatic weakness, always so trying to the patient and to his friends, a period inseparable from the breaking of the habit in whatever way it is done. The cure which these patients undergo is akin to the Weir-Mitchell treatment; the most important thing is the accustoming of the patient to gradually smaller doses and the firm exclusion of morphia from any outside source, which is not easy to secure.

In chronic metal poisoning, especially in chronic lead and mercury poisoning, gymnastics and especially massage are of the utmost importance.

In acute poisonings, which threaten paralysis of the respiratory and cardiac nerves, massage and gymnastics are always part of the treatment, and often the most important part.

This is particularly the case in poisoning, which is not uncommon, by coal gas, carbon monoxide, or carbonic acid.

All cases of threatened suffocation may be considered cases of carbonic acid poisoning.

In all these cases there are three special indications for treatment : -

(1) To clear the air passages from all which may impede the free entrance of fresh air (often from large pieces of food in the oesophagus pressing upon the trachea, from tight bands round the neck, most often from injurious gases or from water in the respiratory tract).

(2) By means of artificial respiration to restore normal exchange of gases in the lungs.

(3) By means of artificial respiration and other means to restore the activity of the heart.

The commonest death from asphyxiation is by drowning, which may therefore be taken as the type for treatment, but, of course, mutatis mutandis. I describe here the treatment of a person apparently drowned.

* The method by which all supply of morphia is suddenly stopped is now out of date. It is certain that it works against itself by the threatened collapse in all cases where morphia has been used for any length of time or in large doses. The Erlenmeyer method, which stops all doses of morphia in eight to ten days, may occasionally in very light cases be carried out, but in the great majority of cases one is compelled to act more carefully and to diminish the daily dose very cautiously. If, after completely accustoming the patient to be without morphia (which should be after several weeks at least), one is not able to keep the patient for several months under one's own control or that of some reliable person, one may take for granted that a relapse will occur.

Marshall Hall's method consists, as is well known, in rolling the patient from side to side from the prone position in order to compress and expand the sides of the chest alternately.

In Howard's method the operator places himself astride the patient's body, the patient lying on his back with a cushion under the lumbar region and the lower part of the thorax; the operator then compresses the lower part of the chest at the rate of sixteen times per minute and allows it to expand by its own elasticity.

According to Silvester's method, the patient is placed on his back with the upper part of the trunk raised. Artificial respiration is given in the following manner : - The operator, placed behind the patient, grasps the patient's elbows with both hands, and at the rate of about sixteen times per minute carries the arms up to the side of the patient's head, and then lowers them, pressing them against the lower part of the thorax. In this way expiration and inspiration are produced alternately.

In Sweden the excellent apparatus invented by the Swedish physician, Dr. K. A. Fries, for producing artificial respiration is coming into use. This apparatus, by means of levers, produces ventilation of the lungs up to a capacity of 2 1/2 litres.

Whichever method is employed, the work should be continued until the patient himself takes fairly deep breaths, which may be brought about a long time, perhaps some hours, after he has been without any sign of life.

The patient's tongue must be drawn forward throughout. As he begins to recover, tea, coffee, ether, etc., should be given.

I consider Dr. Fries' method the best of all. For my part I consider that one should always fulfil the first indication : to clear the air passages of all extraneous matter such as water, etc. To do this the patient is held for a short time in the prone position with the pelvis considerably higher than the head (with the help of several people), and then rhythmic pressure is applied to the sides of the thorax. I also consider that in Silvester's method, which is still the most commonly used, strong effleurage applied by two people over the lower extremities at the same time does much to cause a return of circulation.

This is probably also the case in regard to the effects of general massage after snake bite, where the common symptoms of collapse might well be counteracted. This treatment, however, is very little used, whether in Europe, where we rarely meet with the results of snake bite, or in other parts of the world where the most dangerous forms of bite are those of crotalus, trigonocephalus, naja, etc., which often cause death. The local symptoms consist of oedematous infiltrations, sometimes followed by gangrene, and might well be treated by effleurage; but it must be remembered that this treatment would help to spread the poison unless thorough local treatment of the wound had first been carried out by ligature, incision, cauterisation, etc. Here, as in all other cases, mechano-therapy must not be the only means thought of; it should be used in conjunction with other treatment, especially alcohol, about which opinions are divided. Some medical men use it only as a preventive of collapse and heart paralysis, and in moderate doses; others use it as a specific antidote, and in very large doses. The last method is in common use in North America, and has proved most efficacious in saving lives which would otherwise have been lost from dangerous bites from snakes, the cobra, or the moccasin snake. Should I have to treat such a case, my method of procedure would be as follows : - First, local and energetic treatment by ligature, cauterisation, or sucking away the poison, followed by injections of permanganate of potash, or serum treatment, much spoken of in these days, but a remedy of which I know little. After this large doses of whisky or brandy should be given, together with respiratory movements for hours or until the symptoms of poisoning disappear, alternating with general massage, preferably given by several people at once, with effleurage of the extremities and strong abdominal kneading.