Graham in his text-book on Massage states: "In almost every conceivable form of weak and diseased heart I have been called upon to do massage, and usually with marked relief and comfort, before Schott or Oertel were ever heard of. While it was being done and for some time after, the patients have generally been able to lie on either side or flat on the back, and often to go to sleep in this position - what they could not have done before. In other cases, when it was possible for them to lie down at all, I have masseed with relief until within a short time of their deaths."

In this connection it is interesting to note Kleen's criticism of the heart treatment devised by Prof. Oertel, of Munich. He describes the massage technique advocated as "an absurd novelty," and adds, "this massage seems almost useless, like all that Prof. Oertel has written on the physical treatment of heart disease, beyond what has for long been practised in Sweden ..." (See "Massage and Medical Gymnastics," p. 56.)

Graham also gives the accounts of different observers of the effect of massage on the heart. Very considerable reduction in size can be noted through the fluorescent screen after massage. A similar effect can, however, sometimes be noted by spraying the precordium with ether. This would prove beyond question that it is possible to secure some form of reflex effect upon the heart by local treatment. Experiments to ascertain whether the spraying of other parts - say the back or abdomen - would have a similar effect are not apparently recorded. Without this "control," the evidence of direct reflex via the precordial area must be considered as inconclusive. Most of us are familiar with a sensation of breathlessness when our feet first touch the water on a cold day, as we enter the sea for our morning bathe. This may well owe its origin to reflex action on the heart.

One physician, whose opinion commands respect by reason of wide experience of the treatment of heart cases by massage, affirms that the benefit of local heart treatment is psychical and not physical. This is probably true, and, if so, the treatment is obviously safe. If mechanical effect is secured it can only be regarded with doubt and misgiving.

We know, however, that one of the main causes of the symptoms of muscle fatigue is the accumulation of waste products within the muscle. The victim of heart trouble is always deprived of exercise, by which alone this poisonous material can be eliminated with success. Moreover, if a heart is weakened by disease, the kidneys rarely, if ever, perform their function efficiently. Thus it comes about that the heart-muscle must inevitably be fed by blood rich in waste products. The muscle fibres are therefore "fatigued" by poisons circulating through them; and, being weakened, they are all the more susceptible to this malign influence. A vicious circle is thus established. The heart fails, waste products collect, and the heart fails still more.

The objective in view when massage is ordered in any case of failing heart, from whatever cause, is therefore plain. It is to aid the elimination of waste products and to assist the heart's action, as far as lies in our power, by lowering any resistance which may be present in the venous system impeding the arterial circulation. Both these objectives can be secured by massage treatment, but there is yet another way in which massage can aid our patient. It has been said in an earlier chapter that a dose of morphia or heroin can do more to stimulate the heart's action, in suitable cases, than all the stimulants in the pharmacopoeia combined, simply by affording the patient sleep and rest. Massage can effectively replace this dose.

When called upon to treat a heart patient we should therefore always aim at securing a marked sedative effect from our massage. Indeed, this may be all we are called upon to do during the earlier stages. If the patient is restless, in distress, and tired from lack of sleep, we have in massage the best remedy of all for him. Surface stroking of head and neck may be all that the sufferer needs to ensure several hours of profound sleep. In a few days similar treatment of the arms, and then of the legs, may be added.

As soon as the patient's capabilities of resting are showing signs of improvement, the surface stroking should gradually be replaced by deep stroking, given about the middle of the treatment devoted to each limb. As the patient improves, kneading of the limbs may be added, in order further to assist the circulation. This movement should be performed slowly, gently and rhythmically, and the seance should always begin and end with surface stroking. The patient thus experiences the sedative effect of the treatment, and, at the same time, we are able to secure an increased output of urine and to give a considerable impetus to the elimination of waste products. The assistance we give to the venous flow also decreases the work of the heart, and so we are attacking the vicious circle at all points.

As soon as kneading movements can be performed with benefit, it is well to commence the administration of relaxed movements. These, by allowing the alternate lengthening and shortening of the muscles, maintain their elasticity, assist the venous flow, and stimulate the circulation through the parts moved. The patient is then taught to contract various muscle groups actively, even though no active movement is allowed to follow as the result of the contraction.

Presently the patient will be able to submit to abdominal massage. Previously this may have been impossible, as patients with valvular disease and failure of compensation are rarely able to lie down. If the trouble is due to asthenia of the muscle from any cause - usually strain, as the result of excessive training or exercise, fatty infiltration, or some prolonged septic illness-the patient will find difficulty in sitting up. Massage treatment is contra-indicated for cases of fatty degeneration and all acute endocardiac conditions. We have, then, a sure guide as to when it is wise to begin abdominal treatment, namely, in cases of valvular disease as soon as the patient can lie down, and in cases of myocardial trouble as soon as he can sit up, though the treatment will probably be given with the patient recumbent.