One method of dealing with hysterical spasm is worthy of notice. It, too, is an intensive treatment, and consists simply and solely of tiring out the contracted muscles. The contracture is gradually overcome by constant pressure until full movement in the opposite direction is secured. This may take some time, but can be accomplished with patience. Massage may be invoked to assist in securing the relaxation, and should consist chiefly of firm muscle kneading and deep stroking. Evenness of movement is essential. As soon as the limit of movement is reached all restraint is removed, and the contraction returns. Immediately the process is repeated time after time, till finally, from sheer exhaustion, the spasm fails to return. It is often a long and tiring process for patient and masseur alike, and the pain inflicted may be very considerable. It is, however, very effective, and particularly if the patient is adequately prepared beforehand for his "cure."

Ordinary training in massage does not, and cannot, include training that shall enable the masseur to deal successfully with this type of illness, and it is not my purpose here to try to fill the gap. What I want to emphasise is this. According to Colonel A. F. Hurst, of Seale Hayne fame, hysteria should be defined as "a condition in which symptoms are present which have been produced by suggestion and are curable by psychotherapy.1 If hysterical disability can be cured by persuasion so, too, can it be implanted by persuasion, and herein lies one of the chief dangers of all massage treatment.

Any illness or injury which produces any disability, however slight, conveys to the mind a consciousness of disability. To recover from this disability, mental effort on the part of the patient is essential. Without it the disability will persist, perhaps long after the actual cause of the trouble has been remedied. It may even be that recovery of function will entail voluntary effort the result of which is not free from pain. Unless the patient is taught and encouraged to regain function in spite of this, he may well regard the slightest discomfort in movement as akin to disability. He must know and realise that this is not so if he is to recover. But equally we must know how much pain or discomfort a patient may with benefit inflict upon himself: how far voluntary effort may wisely go. Attention to our three golden rules provides the solution. If there is no increase of pain or of swelling and no decrease in mobility let him persevere.

If, on the other hand, the patient relies on massage to cure him, what is the result? Let us suppose he is strong enough to abduct his arm fifteen degrees. Considerable effort may enable him to reach twenty degrees a few days later. Unless he makes this effort he will never do it, not with all the massage in the world. If he is taught to rely on massage to do it for him, he will not make the effort, and recovery will be indefinitely postponed; and the masseur who inculcates the belief that massage will effect the cure is really responsible for inflicting on his patient a "functional" disability.

1 The Lancet, 1919, p. 771.

As has been stated over and over again in these pages, massage is merely a means to an end, and that end is restoration of function. If the function is under voluntary control, nothing but the exercise of volitional effort can ever cure the patient. Let us beware, then, lest by our attitude and actions, expressed or implied, we convey to our patients the lamentably erroneous idea that we can cure them and that all they have got to do is to let us do it for them. It is so easy to convince a patient of evil, to convey to him that his disability or weakness is worse than it really is: it is often extremely hard to convince him that these things are less than he believes. Yet unless we do this, it is not likely that he will make the effort which alone will cure him, and we confirm - or at best allow him to confirm - his disability.

If there is one motto that should be hung up over the door of every massage school it is this - "Massage alone rarely cures." Patients have to be taught to cure themselves. We can prepare the patient for cure, and render cure possible; we can teach him how to cure himself; but, in the long run, "cure" is dependent on the patient and his own volitional effort. Without his cooperation our best efforts are rendered void and useless.

Take, for instance, a case of constipation. However much we work upon the abdomen the patient will never be cured till he practises regular habits. Or, again, consider a case of muscular rheumatism. There is definite disability from pain. Massage can relieve the pain and assist the removal of deposits in the muscles, but it cannot cure the disability unless the patient uses his own muscles. We cannot use them for him and disability remains, until he exerts volitional effort, possibly long after the condition that caused it has vanished. Even a case of insomnia depends for ultimate cure more or less on volitional effort. The power of relaxation is lost - it is without the field of volition. We can, by massage, restore the power of relaxation, pull it back, as it were, to within the field of volition. We can teach the patient to regain the lost control of mind and body, and can show him how and why the control was lost.

Nothing we can do can secure him from relapse, unless he voluntarily allows himself adequate opportunity for sleep in the future.

I hope enough has been said to impress the fact that "massage" does not consist of mechanical manipulation. Every patient must be made to understand the personal element in his case, and must be encouraged throughout to make every effort in his power to recover, even if the effort consists solely of voluntary relaxation. The great danger that invariably besets us, when we undertake to apply massage to a case, is that we thereby convey to the patient that we are going to do all that is necessary for him, that we thus detract from volitional effort, and so confirm or even create a "functional" condition that may be little short of hysterical.

There are always to be found a few optimistic patients who are anxious to hasten recovery more than is advisable. They are the exception, and not the rule. It is far more common to find patients erring on the side of caution, and of making too little sustained effort towards recovery than the reverse. This is not because they do not want to get better quickly; it is because of the influence expressed or implied during treatment. When patients submit to treatment at all, they naturally expect help and guidance. Many obey orders implicitly, even to the extent of omitting anything and everything that is not specifically ordered. For instance, it is not uncommon for a charwoman who is recovering from a Colles' fracture to ask if she may try to scrub a little. If she has reached the stage of recovery at which the answer is in the affirmative, what would have happened had she not asked? The attempt would not have been made, and recovery of function would have been postponed. In other words, functional disability would have been prolonged owing to absence of specific instructions. In this sense the chief sin of the masseur is one of omission: it is often more fertile of delayed recovery than that of commission.

Until the masseur realises that his duty does not cease with his manipulation, but that he must also be prepared to treat his patient's mind, to encourage volitional effort, to prescribe movements first and then activities - massage as a remedial agency will continue to fail us. The term "massage" must be made to include physico-therapy, and every known trade, occupation, exercise and movement must be classed under this term. It is far better, for instance, to scrub than to "exercise," or to play the piano than to drum aimlessly with the fingers on a table or in the air. The set exercise must always aim at securing some special movement or some special activity: it cannot replace the ordinary daily use. But even this wide interpretation of the term "massage" is inadequate. Not only must our work be physical, it must be psychical as well. It cannot be neutral, and the psychical effect of our treatment must tell either for recovery or against.

Let us see to it then that our influence is for good towards our patients, that we prepare the way for recovery, show how recovery is possible, take every advantage we can of what is favourable and render as slight as we can all that is unfavourable. Let us maintain to the full the preservation of function that has not been completely lost, secure the earliest possible return of movement, of co-ordination and of function when lost; and do all in our power to preserve intact the full volitional capacity of our patients, on which alone we rely for the present rapidity of recovery and our ultimate success.