Fat and Blood, Chapter VI: Massage (S. Weir Mitchell)

S. Weir Mitchell
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Webmaster's Notes:

Fat and Blood: An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria, by S. Weir Mitchell, has been included on this site because Dr. Mitchell's famous "Rest Cure" was instrumental in changing the course of Charlotte Perkins Gilman's life, and, indeed, the infamous cure was cited several times by Gilman.

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Fat and Blood Table of Contents

FAT AND BLOOD: AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF
NEURASTHENIA AND HYSTERIA.

How to deprive rest of its evils is the title 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 massage and electricity. We
have first to deal with massage, 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.

Massage 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 Japan 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 massage 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 massage 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 massage" follows.

After three or four days in bed have somewhat accustomed the patient to
the general routine of treatment, a masseur or masseuse 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 mass 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 masses, then by careful deep kneading
(pétrissage) 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 masseur.

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 prone, 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 scapulæ, 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
spinæ masses 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
prone to the supine position. In women the breasts are usually best left
untouched unless special conditions demand their treatment.

The last and perhaps most important part of the process of general
massage 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 massage" 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 masseur. 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
massage that nothing is here said about the use of the movements classed
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 constitutes one of the defects of the system of
massage as usually practised by the Swedish operators; and when patients
tell me, as many do, that "they cannot stand massage," it is often found
that the performance of a great deal of this useless and fretting
manipulation has constituted 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 massage 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 massage. As to time, at
first the massage 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
masseuse 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 massage 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 massage 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 massage, 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 massage is so disagreeable or
produces such annoying nervousness as to make manipulation impossible;
sometimes, though very rarely, massage, especially frictional movements,
causes sexual excitement when applied in the neighborhood of the genital
organs, or even on the buttocks 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 massage 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 massage 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 passive and extreme extensions and flexions of the limbs for
a few days, then assisted movements, next active unassisted movements,
and last active movements gently resisted by nurse or masseuse. 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 massage 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 massage 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
massage, 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 massage, 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 quantity, and because
occasionally some other and less comprehensible factors actually induce
a fall rather than a rise in the thermometer as a result of massage.

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 anæmic 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
massage 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 interstitial 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 massage. This study,
although it was never completed in a satisfactory manner, would seem to
show that massage 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 illustrate the facts above
stated as to rise of temperature.

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

Before Massage.-----After Massage.

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., æt. 24, hysteria:

Before Massage.-----After Massage.

99-1/4--------------99-1/4

98-1/4--------------99

98-1/2--------------99

98-1/4--------------99

98-1/4--------------98-1/4

99-------------------99-3/4

100-1/5-------------100-2/5

100-2/5-------------101-2/5

100-2/5-------------100-3/5

100-3/5-------------100

Mrs. L., a very thin, feeble, and bloodless woman, æt. 29 years:

Before Massage.--After Massage.

99--------------100

98-1/2----------99-1/5

98---------------98-2/5

99---------------100

98-2/5----------98-4/5

99---------------99-4/5

100-------------100-1/5

99---------------99-4/5

Mrs. P., æt. 31, feeble and anæmic, nervous, slight albuminuria and
chronic bronchitis. Liable to fever. 3 P.M.:

Before Massage.---After Massage.

101-3/5--------------102

100------------------100-4/5

99--------------------99-4/5

100------------------101

99-2/5---------------100-1/5

99-4/5---------------100-3/5

100-3/5--------------101-3/5

100-2/5--------------99-4/5

100-3/5--------------100-2/5

100-3/10-------------100-9/10

99-1/5----------------99-4/5

These temperatures were taken always before 4 P.M., and at intervals of
three days. Her morning temperature was usually 99° to 99-4/5°, and in
the evening, 9 to 10 o'clock, it always rose to 100°, 101°, and at times
to 102°.

As I have said already, there are persons who, under circumstances
seemingly alike, have from massage a large rise of temperature, and
others who experience none. I give a single case of what is rare but not
exceptional,--an almost constant fall of temperature.

Miss N., æt. 21, hysteria, good condition:

Before Massage.---After Massage.

98----------------97-3/5

98-1/2------------98-1/2

98-----------------98

98-2/5------------98

98-4/5------------98

These facts are, of course, extremely interesting; but it is well to add
that the success of the treatment is not indicated in any constant way
by the thermal changes, which are neither so steady nor so remarkable as
those caused by electricity.

If now we ask ourselves why massage does good in cases of absolute rest,
the answer--at least a partial answer--is not difficult. The secretions
of the skin are stimulated by the treatment of that tissue, and it is
visibly flushed, as it ought to be, from time to time, by ordinary
active exercise. Under massage the flabby muscles acquire a certain
firmness, which at first lasts only for a few minutes, but which after a
time is more enduring and ends by becoming permanent. The firm grasp of
the manipulator's hand stimulates the muscle, and, if sudden, may cause
it to contract sensibly, which, however, is not usually desirable or
agreeable. The muscles are by these means exercised without the use of
volitional exertion or the aid of the nervous centres, and at the same
time the alternate grasp and relaxation of the manipulator's hands
squeezes out the blood and allows it to flow back anew, thus healthfully
exciting the vessels and increasing mechanically the flow of blood to
the tissues which they feed. It is possible also that a real increase in
the production of red corpuscles is brought about by repeated
applications of massage, as will be seen later on.

The visible results as regards the surface-circulation are sufficiently
obvious, and most remarkably so in persons who, besides being anæmic and
thin, have been long unused to exercise. After a few treatments the
nails become pink, the veins show where before none were to be seen,
the larger vessels grow fuller, and the whole tint of the body changes
for the better.

In like manner the sore places which previously existed, or which were
brought into sensitive prominence by the manipulation, by degrees cease
to be felt, and a general sensation of comfort and ease follows the
later treatments.

Although this plan of acting on the muscles seems to dispense with any
demands upon the centres, it is not to be supposed that it is altogether
without influence on these parts. In fact, extreme use of massage
occasionally flushes the face and causes sense of fulness in the head or
ache in the back. The actual large increase in the number of corpuscles
in the circulation brought about by massage may be one of the reasons
for this. We have added, perhaps, millions of cells to the number in the
vessels in a very short time, and need not be astonished if some signs
of plethora follow. Moreover, in some spinal maladies it has effects not
to be altogether explained by its mechanical stimulation of the muscles,
nerves, and skin.

That the deep circulation shares in the changes which are so obvious in
the superficial vessels has been shown by various observers of
experimental and clinical facts. Firm deep muscle-kneading of the
general surface will almost always slow and strengthen the pulse. If the
abdomen alone is thoroughly rubbed the same effect appears in the pulse,
but less in degree, and massage of the abdomen has also a distinct
effect in increasing the flow of urine, a fact worth remembering in
cases of heart-disease. In a case of albuminuria from exercise, W.W.
Keen has shown that massage did not cause the return of the albumin
after rest, though exercise did, a difference due to the opposite
effects upon blood-pressure of the two forms of activity. Lauder-Brunton
has shown that more blood passes through a masséed part after treatment.
Dr. Eccles and Dr. Douglas Graham both found a decided decrease in the
circumference of a limb after massage, showing how completely the veins
must have been emptied, for the time at least,--an emptying which would
surely be followed by an increased flow of arterial blood into the
treated region. Dr. J.K. Mitchell, in 1894,[21] made a large number of
examinations of the blood before and after massage, some in patients
under treatment for a variety of disorders affecting the integrity of
the blood, and a few in perfectly healthy men. With scarcely an
exception there was a large increase in the number of corpuscles in a
cubic millimetre, and an increase, though of less extent, in the
hæmoglobin-content. Studies made at various intervals after treatment
showed that the increase was greatest at the end of about an hour, after
which it slowly decreased again; but this decrease was postponed longer
and longer when the manipulation was continued regularly as a daily
measure.[22] The author's conclusions from these examinations were
interesting, and I quote them somewhat fully. The fact that the
hæmoglobin is less decidedly increased than the corpuscular elements
makes it seem at least probable that what happens is, that in all the
conditions in which anæmia is a feature there are globules which are not
doing their duty, but which are called out by the necessities of
increased circulatory activity brought about by massage. If this is the
first effect, yet as it is observed that the increase of corpuscles, at
first passing, soon becomes permanent, we must conclude that massage has
the ultimate effect of stimulating the production of red corpuscles.

One sometimes hears doubts expressed whether a patient with a high-grade
anæmia is not "too feeble for such strong treatment" as massage. This
study of one of the ways in which massage affects such cases may fairly
be taken as proof of the certainty and safety of its effect on them,
provided always it be done properly and with intelligence. Some check
upon this may be had, as is said elsewhere, by the general effect upon
the patient. It may be repeated that the pulse should be slower and
stronger after an hour of deep massage, and that this effect will not be
produced by superficial rubbing (indeed, with light or too rapid
manipulation the pulse may become both less strong and more rapid), and
finally the flow of urine should be increased. With these easily
observed facts to aid, it may readily be judged whether massage is being
rightly applied or not without the need of a visit from the physician
during the hour of treatment. A final test might readily be made by
examination of the blood and counting the red corpuscles before and
after treatment. No doubt in very bad cases a small increase or none
would be found at first, but a week of daily manipulation should show a
distinct addition to the blood count. A striking instance in which this
examination was repeatedly made is related on p. 184.

"It is evident that our present definitions of anæmia are insufficient.
An essential part of the description in all of them is that there are
defects of number, of color, or of both in the blood. This is not
necessarily or always true. The fault may lie in a lack of activity or
of availability in the corpuscles. The state of things in the system may
be like the want of circulating money during times of panic, when gold
is hoarded and not made use of, and interference with commerce and
manufactures results.

"Neither an anæmic appearance nor a blood-count is alone enough for a
certain diagnosis. Other signs must be used as a check on the blood
examination for the establishment of the existence of anæmia. For
instance, many cases here recorded had full normal or even supra-normal
corpuscle-count, with a good percentage of hæmoglobin. Yet they
presented every external sign of poverty of blood: pallor of skin and,
more important still, of mucous membranes, cold extremities, anorexia,
indigestion, dyspnoea on trifling exertion. In such cases we must suppose
either that the total volume of the blood is reduced, or that the
usefulness of the corpuscles is in some way impaired, or that both these
troubles exist together."[23]

I have said above that the face was not touched in the course of the
rubbing. There are cases, however, in which massage of the head and face
may be usefully practised. Some obstinate neuralgias are helped by it
temporarily, and very often it is of use with other means to aid in a
permanent cure. Many headaches of a passing character may be dissipated
promptly by careful massage of the head or by downward stroking over the
jugular veins at the sides of the neck to lessen the flow of blood into
the cerebral vessels, where the pain is due to congestion or distention,
and careful manipulation of the facial muscles in paralysis is of
service in restoring loss of tone and improving their nutrition. It is
worth adding here, as women patients frequently say that during their
illness the hair has become thin or shown a great tendency to fall, that
daily firm finger-tip massage of the head for ten or twelve minutes,
followed by rubbing into the scalp of a small amount of a tonic, either
a bland oil or if need be of some more stimulating material, will in a
great majority of the instances where loss of hair is due to general
ill-health perfectly restore its vigor and even its color.

I am accustomed to pay a good deal of attention to the observations made
on these and other points by practised manipulators, and I find that
their daily familiarity with every detail of the color, warmth, and
firmness of the tissues is of great use to me.

A great deal of nonsense is talked and written as to the use and the
usefulness of massage. The "professional rubber" not unnaturally makes a
mystery of it, and patients talk foolishly about "magnetism" and
"electricity;" but what is needed is a strong, warm, soft hand, directed
by ordinary intelligence and instructed by practice; and this is the
whole of the matter, except in the massage of such obscure conditions
as need full knowledge of the anatomical relations and physiological
functions of the parts to be rubbed. It is a fact that I have known
country physicians who, desiring to use massage and not having a
practitioner of it within reach, have themselves trained persons to do
it, with considerable resultant success.

It is not, perhaps, putting it too strongly to say that bad massage is
better than none in those cases in which manipulation is needed. Very
little harm can result from its use even by unskilled hands, provided
that reasonable intelligence direct them.

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FOOTNOTES

[Footnote 16: "Pinch" is used to avoid the use of a technical term, but
should be understood to mean the grasping and squeezing of a part with
the whole hand, using the palmar portion of the fingers to press the
grasped mass against the "heel" of the hand. Fuller technical details of
the massage process and consideration of its effects will be found in
the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham,
Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's
"System of Medicine" (1896), by Dr. John K. Mitchell.]

[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends
this order.]

[Footnote 18: Some care is needed not to overwork patients. For details
I must refer to manuals of Swedish Gymnastics.]

[Footnote 19: See also page 91.]

[Footnote 20: A number of observations in late years have been made upon
the effect of massage upon elimination. Among the articles to which the
practitioner desiring further to study this subject may be referred
are,--

_Edin. Clin. and Path. Jour_., Aug., 1884.

_Jour, of Physiol._, vol. xxii., p. 68.

_Centralbl. f. Inner. Med._, 1894, No. 40, p. 944.

_Munch. Med. Woch._, April 11 and April 18, 1899 (Influence of bodily
exercise upon temperature in health and disease).

Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque
and Marette, and Maggiora.]

[Footnote 21: American Journal of the Medical Sciences, May, 1894.]

[Footnote 22: Numerous examinations made since have quite uniformly
agreed with the former remarkably constant results.]

[Footnote 23: J.K. Mitchell, _loc. cit._]

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Original publication information:

FAT AND BLOOD: AN ESSAY ON THE TREATMENT OF CERTAIN FORMS OF NEURASTHENIA AND HYSTERIA.

BY S. WEIR MITCHELL, M.D., LL.D. HARV., MEMBER OF THE NATIONAL ACADEMY OF SCIENCES.

EIGHTH EDITION.

EDITED, WITH ADDITIONS, BY JOHN K. MITCHELL, M.D.

PHILADELPHIA: J.B. LIPPINCOTT COMPANY.

LONDON: 5 HENRIETTA STREET, COVENT GARDEN 1911.

Copyright, 1877, by J.B. LIPPINCOTT & CO.

Copyright, 1883, by J.B. LIPPINCOTT & CO.

Copyright, 1891, by J.B. LIPPINCOTT COMPANY.

Copyright, 1897, by J.B. LIPPINCOTT COMPANY.

Copyright, 1900, by J.B. LIPPINCOTT COMPANY.

Copyright, 1905, by S. WEIR MITCHELL.

ELECTROTYPED AND PRINTED BY J.B. LIPPINCOTT COMPANY, PHILADELPHIA, U.S.A.

Etext from Project Gutenberg.

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