To use massage aright we must consider it entirely as a means to an end, the end being restoration of function. Every movement performed should have this end in view; and the masseur should be able to show, in reasoned detail, what effect it is hoped will result from each movement of hand or finger, and what part this effect is expected to play in the restoration of function. More than this, there should be a reason for every attitude assumed by the masseur, and for the position in which the part under treatment is placed - which joints are flexed or extended, which muscles are kept in tension and which relaxed. Thus in treating an arm it may be wiser to treat one patient sitting up, another standing, and a third lying down. For the treatment of the leg one patient should be recumbent, another prone, and a third sitting. Attention to details of this kind may make all the difference between success and failure, and so it is absolutely necessary that we should regard them as essential, and be prepared to support by reasoning and argument every detail of our treatment however apparently insignificant.

Massage being then merely the means to an end, we must first consider what effects we may expect from the exercise of these means.

There are two, and only two, possible effects of any movement of massage: - reflex and mechanical.

Reflex Action of Massage.

A. In Massage of the Limbs. - It is still possible to find those who are inclined to scoff when the "reflex action of massage" is mentioned. It is, none the less, as important as the mechanical effect. The desire for massage is instinctive, and several points in massage treatment may be learnt from the most simple of nature studies.

A dog whose leg is run over seeks some quiet spot, lies down, and begins to lick the injured leg with a slow, gentle, rhythmical movement which is perfect because it is natural, and which should serve as a pattern to all masseurs. Nature prompts the animal thus to treat his injured limb - his treatment is not necessarily applied to a wound, as it is the same whether the skin be broken or not - and when we see that the slow, gentle, rhythmical massage brings him ease and comfort and at the same time hastens his recovery, surely we should copy as best we may and apply treatment that corresponds to it closely to our injured fellow men. Again, when we sit down after a heavy day of mental effort, perhaps the most common action is for the hand to be passed lightly and gently over the tired eyes and forehead, instinct teaching us that this movement will bring a sense of relief. Surely then, again, similar treatment is indicated for those who suffer from the chronic fatigue of neurasthenia. We know from nature and from our own experience that this stroking massage is capable of yielding comfort, and yet it is so light that its effect cannot conceivably be due to mechanical causes: the only possible way, therefore, in which it can act is by nerve reflex. Moreover, we all recognise certain reflexes which result from skin stimulation - the abdominal, plantar, and cremasteric reflexes. We also recognise the involuntary emptying of the stomach on tickling the back of the throat, and, almost the converse, the relief of hiccough that can be secured by tickling the anterior nares. It is only reasonable to suppose that, if one form of surface stimulation can produce a muscular contraction by reflex, another form of stimulation can secure relaxation.

In every-day life we recognise the beneficent effect of massage every time that we rub our eyes hard to reduce intra-ocular tension, or press upon temple or forehead after a day of great fatigue, when the blood pressure is high, in order to secure the relief that follows local reduction of blood pressure, even though the general pressure is not altered. It is thus that we instinctively invoke the aid of massage for its mechanical effect.

Passing from argument to fact, those who have once seen the treatment first devised by Lucas-Championniere applied to a recent fracture cannot but admit that they have witnessed the result of a profound reflex. A patient may have suffered severe comminution of the neck of the humerus. Before treatment he is in obvious agony, and on inspection the injured arm is visibly shorter and thicker than its fellow. Under the influence of massage the pain passes off, and then the arm slowly becomes longer and thinner under our touch, till finally it may be difficult to note the difference between the two limbs. In the same way, it is often possible to overcome the spasm which causes the shortening and deformity due to muscular spasm after fracture of the femur - a shortening it may be almost impossible to correct even when aided by anaesthesia. By massage we can relieve the spasm, even if we cannot always reduce the deformity.

The most noticeable result when massage is applied to a limb which has sustained a recent fracture is the transient nature of the subsequent swelling. This is often attributed to the mechanical effect of the massage, and yet the swelling may subside with equal rapidity whether the stroking is performed centrifugally or centripetally. In the former case mechanical action is inconceivable. If, however, we are only seeking a reflex effect, it is clearly immaterial whether our stroking is performed upwards or downwards.

B. In Massage for Diseases of the Nervous System. -In the treatment of an irritable neurasthenic, the victim of insomnia, if we watch the nervous irritable twitching slowly pass off as we proceed, see the anxious facial expression change to one of repose, and finally hear the regular deep breathing of a sleep, which is so sound that we can adjust the bed-clothes, wash, dress, turn out the light, open and shut the door, all without disturbing the sleeper, we can feel no possible doubt as to the reflex action of the massage we have given. Sometimes it is taught that the effect is due to relief of "congestion in the head." The patient with arterio-sclerosis and high blood-pressure, who sleeps badly, may owe his trouble to "congestion," but the typical victim of insomnia has a low blood-pressure, and intra-cranial congestion is almost inconceivable. Moreover, many patients become drowsy before the head or neck are touched; and, when they are treated, the touch is far too gentle to secure any mechanical effect whatsoever. Further, if massage, of the type that aims at securing mechanical effect, is administered to the neurasthenic with firmness and vigour, the result is often disastrous. This point will be further elucidated (see Chapter XXI (Massage Treatment In Neurasthenia).).