In general massage for obesity all the movements are characterized by pressure, and may, broadly speaking, come under the head of pétrissage, but they are done on the superficial tissues ; it is impossible to get at muscles in the ordinary way through a wall of fat. Exercises of the joints are relied on for acting on the muscles.

Firm stroking on the limbs with the palms of both hands working simultaneously.

Pincement is substituted for thumb and finger kneading, the skin and superficial fascia being well rolled and squeezed.

Fulling is very suitable, especially when the fat is hard and the skin tight, not so much for the pressure, but because it stretches and moves the tissues on each other.

Squeezing.—Large masses are seized with both hands and squeezed.

The flexures of all joints where fat is wont to accumulate must receive special attention, being well worked into by friction, kneading, and firm effleurage. They must be flexed as thoroughly as possible, and extended to the utmost. After treating the abdomen in the usual way, the walls are treated to further and more vigorous kneading, pincement, and fulling.

For neck and chin pincement and effleurage.

The Back.—Effleurage with both flat hands, working together from neck to sacrum.

Kneading all over, from spine outwards, with thumbs and heel of hand.

Fingers placed at neck on one side of spine, thumbs on the opposite side, to be drawn towards each other, making two rolls of fat between ; one hand follows the other down to sacrum.

Fig. 93-—Pincement.

Pincement in lines from neck down on each side of spine.

Hands laid flat, palms down, the left on patient's right shoulder, the right on patient's left shoulder rather lower, fingers of both pointing from operator, who is supposed to be at patient's left side, left hand is drawn back while right is pushed forwards : this is repeated down the back, the hands passing and repassing each other, making a sort of twisting movement. Fairly firm pressure is used, but on the muscles, not on the skeleton.

Rapid and vigorous fulling. Chopping, flail, clapping.

Fig. 94.—Pincement.

Fig. 95.—Squeezing Superficial Tissues in Obesity.

There is frequently a lump of fat at the back of the neck almost or quite devoid of feeling ; this is pressed and squeezed.

All kneading movement to be used on buttock, also fulling.

Exercises.—1. Patient lying supine, to rise to sitting position without aid of arms.

2.   All movements of legs and arms against resistance.

3.   Body flexed laterally, backwards and forwards against resistance.

It must be borne in mind that these patients are physically unable to take sufficient exercise, and that one object in giving them massage is to make up this loss to them. It should, therefore, be of a vigorous and stimulating kind, and the exercises resistive ; they should not remain in bed after treatment, but dress and move about immediately. At the same time, it must be remembered that these patients are quickly tired, and discretion must be used.