Hemiplegia is one of the most disheartening conditions that the masseur is called upon to treat. There is, however, this much of comfort for us, that, without our aid, the patient's condition would pass from bad to worse. It is only occasionally that our efforts will fail to be rewarded by evidences of actual progress towards recovery, and the gratitude received will amply compensate for any trouble taken. The patient invariably attributes to the massage the recovery that may be made, and to a certain extent he may be justified. Nature should, however, receive her meed of thanks.

It is true that, generally speaking, the right side of the body receives its innervation from the left side of the cerebral cortex, and vice versa. But there are inter-communicating fibres from one side to the other, and it would seem that sometimes the left side of the brain can develop a certain amount of control over the movements of the left side of the body. Patient perseverance with massage and passive movements - of necessity they must be relaxed unless contractures are present, when forced movement must be employed - are able to keep the paralysed muscles in readiness for these connecting fibres to play their part. Without our assistance the communications would doubtless take place, but the muscles would not be able to take advantage of the recovery. In any case of hemiplegia it is always doubtful at the outset how far recovery will be partial or complete; as, even if the lesion is small, paralysis may be very marked in the early stages, apparently from "shock" sustained by neighbouring structures.

The duty of the masseur is again obvious. General massage of the deep-stroking and gentle kneading types will maintain nutrition. Passive movements will prevent contractures.

Each joint must be treated fully and conscientiously every day. But, as has already been pointed out, paralysis is almost always more extensive in appearance than in fact. Every effort should therefore be made, even in apparently hopeless cases, to encourage the patient to perform voluntary contraction and relaxation in order to assist our movements. Thus, and thus only, can we ensure that muscles which are only temporarily affected will resume their activities, and that we keep the way open, as it were, for the free passage of impulses along fresh paths. Directly there are signs of returning power, the patient will often contract the muscles more readily if slight resistance is offered.

It is well to remember that the patient may have been leading a most active life right up to the moment of the onset of the "stroke." The sudden cessation of full activity is always detrimental to general health, and abdominal massage may add very materially to the patient's well-being. In the earlier stages, however, abdominal massage should be administered with a very sparing hand in all cases of cerebral haemorrhage, as it tends to raise the blood-pressure.

The psychological aspect of the case should also be kept in mind. The visit of the masseur should be a bright spot in the daily routine, and the moral support given in a hopeless case may be of as great importance as any physical benefit that may be rendered.

During recovery of a muscle great care must be taken to avoid fatigue from over-use, and exercise must be duly "spaced" with massage (see p. 231).

Progressive Muscular Atrophy is another of the "hopeless" diseases, in which massage and exercises, though they will not cure, can help very materially. The form usually encountered is known as amyotrophic lateral sclerosis. Generally it begins with "clumsiness" in performing some of the finer hand movements, and spreads continuously. In the early stages massage, muscle training and exercises may effect an apparent cure. This is only because the disease has still left sufficient motor fibres intact to enable us to build up the strength of the muscle fibres supplied by them to such an extent that, through their increase of strength, they are enabled to do their own work so well that the degeneration of neighbouring fibres passes unnoticed. It is a "losing game" in the end, but the masseur who keeps heart throughout the fight may confer inestimable benefit on a patient who, without massage, is deprived of all hope of assistance.

Massage should aim at maintaining nutrition and assisting the performance of exercises. Fatigue must be carefully avoided. All joints must be kept fully supple, as only so can the typical main-en-griffe deformity be averted. Contractures should be countered by every means available. The upper motor neurone may be more affected than the lower. This leads to a spastic paralysis instead of a flaccid. The difference in treatment is as follows: -

In all cases of flaccid paralysis wasting of the muscles is rapid and complete, and all reflexes are lost. In spastic paralysis the muscles may waste very little, and the muscle reflexes are all exaggerated. This gives the clue to treatment. In flaccid paralysis the muscles are in a condition of absolute relaxation and are undergoing degenerative change. The sole aim in performing massage is to secure full and efficient circulation through the muscle, for the double purpose of maintaining nutrition and of removing waste products, which inevitably collect in spite, and even because, of lack of exercise. Without exercise the normal stimulus necessary for an efficient blood supply is not provided; deficiency of blood supply in turn allows waste material to accumulate; and this accumulation again tends to hasten the degeneration of the muscle tissue. Hence we have a vicious circle, which can well be broken by means of massage. But the perfect flaccidity of the muscle deprives every structure in, or covered by, the muscle of the natural protection which is derived from it when the tone is normal. Hence we may regard our massage as applied directly to the blood-vessels. Keeping in mind the delicate nature of the arterioles, and that the influence of massage on these vessels is due to the response of the unstriped muscle in their walls to mechanical stimulation, it is easy to realise how simple it is to overdo massage treatment in these cases. Any excess leads to paralytic dilatation, which means that the stagnation of the circulation - already present to some extent as the result of the paralysis - is increased by our manipulations, and thus the very evil which we are attempting to remedy is actually enhanced. There should, therefore, be three main laws in the treatment of flaccid paralysis: first, the dose of massage administered to any individual muscle, or muscle-group, should be short, but may be repeated on the same day; second, only the most gentle and delicate touch is permissible; third, every care must be taken to avoid pressing the paralysed muscles between the fingers and the bone.