It is beyond doubt that neurasthenic symptoms may develop as a local condition. Treatment must then be carried out on the lines laid down in the previous chapter. But many cases exhibiting similar symptoms are undoubtedly hysterical. Massage by itself fails; massage combined with other methods of treatment may succeed. It is impossible to furnish any guide as to the manner in which these cases should be approached Everything depends on the nature of the concurrent treatment.

If a patient with hysterical paralysis is treated by solitary confinement and other severe measures, probably the best line to adopt is to administer a thoroughly vigorous - and probably equally unpleasant - dose of massage. As pointed out in the previous chapter, this method of treatment should be discouraged. If, on the other hand, the patient is being treated by suggestion, the wisest plan is to apply only the sedative type of massage there advocated, without paying any special attention to the limb that does not move. This will prepare the way for the psychical treatment and help to render the patient more receptive. This line of treatment, however, should only be carried out when the masseur is asked to work in direct co-operation with the medical man who is undertaking the psycho-therapeutic treatment of the case.

Passing on to the treatment of functional disorders in general, we find that a large group of cases have one symptom in common, namely, spasm. This may affect involuntary or voluntary muscle. Raynaud's disease and angina pectoris may probably be taken as typical of the former.

In the treatment of Raynaud's disease there should be two distinct methods of attack. First, presuming that the spasm is due to some nerve lesion, reflex result might be anticipated from surface stroking, and this should undoubtedly be given a chance. If it succeeds in nothing else it will prepare the way for the second method. This is neither more nor less than so to over-stimulate the unstriped muscle of the arterioles that, despite the command of the nervous system to contract, it is compelled to remain relaxed. Hence firm, deep massage is required, and fifteen to twenty minutes may be spent on the treatment of one limb. The benefit will soon be detected by the patient, and the results recorded in relief of pain, a sensation of warmth, and improvement in colour. The proximal portions of the limb should be treated before the distal, and every precaution should be taken not to submit a tender area to heavy treatment at the outset, but to approach it gradually. After massage every muscle in the limb should be exercised.

It is probable that erythromelalgia and angio-neurotic oedema are disorders of similar origin. If opportunity affords, treatment should be arranged on the above lines.

Chilblains, in the ordinary household, are submitted to vigorous rubbing. Historical evidence cannot be ignored, and this time-honoured practice must have something in its favour. On the other hand, purely local treatment of this type can only cause a local hyperaemia which is transient in character. The scientific treatment for this most annoying condition is to treat the whole limb by general massage for the circulation; aiming to secure, by both reflex and direct effect, a general toning up of the whole of the vascular system of the part. The pathology of the trouble is probably that cold, possibly combined with pressure, has caused spasm of the arterioles. Then, owing to the long-continued presence of the spasm, the muscle fibres have become "fagged out" and temporarily paralysed. There is, therefore, little to be said in favour of attempting further to paralyse them by overstimulation. An attempt may, however, be made to stimulate the muscle to contract by the application for very short periods - say ten or fifteen seconds at a time - of vibration or percussion.

In arctic circles true frost-bite is treated by vigorous rubbing to secure vaso-dilatation, as, failing this immediate remedy, the cold is liable to freeze the blood in the part that has been depleted of fluid by reflex vaso-constriction.

The "trench-foot," with which we first became familiar in this country in the early days of 1915, is due to a combination of causes - usually cold, damp and pressure, and probably also to sepsis. In spite of the cold the condition is unknown in Labrador, and Dr. Grenfell has attributed the immunity to lack of pressure.

How far the subsequent evils of trench-foot could be avoided were it possible to administer immediate treatment by massage, it is impossible to say. When the cases arrive home the condition appears to be a combination of neuritis and of general disorganisation of the vaso-motor system. Certain it is that vigorous massage of the foot is a lamentable failure, and definitely postpones recovery.

Treatment should be administered as follows: - Surface stroking of the thigh is begun, and the stroke is gradually lengthened by including more and more of the leg, until the area of sensitiveness is reached. It is then carried no lower. The thigh is gently kneaded, and then the patient is taught to contract every muscle in the limb over which he has control. Exercise without weight - simple swinging or on the sliding-seat - is encouraged, and the seance terminates with firm but gentle stroking for about five minutes. Great patience may be required, and careful watch must be kept for the development of deformities, and these should be appropriately guarded against. The chief are foot-drop and the development of a valgus deformity, either of the whole foot or only of the big toe. The use of a club-foot shoe-splint at night will probably be all that is required. Care should be taken so to pad the splint that the natural contour of the sole is maintained intact. An unpadded splint of this type tends to turn the foot into a valgus position and to destroy both arches. No patient should ever be allowed to walk till all danger of developing these deformities is past. Gradually the stroking may be extended all over the foot, and then kneading may be applied to the leg with great care. Once more the foot is gradually approached. Sometimes it is possible to administer this treatment to the foot itself by grasping it firmly between the two hands and alternately relaxing and tightening the grip. No movement of the hand on the surface takes place (cf. Fig. 90, p. 172). If utilised, this part of treatment should occupy only a very few minutes.