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 scapulae, 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 spinae 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