It should be borne in mind that the fact that a muscle is in a condition of flaccid paralysis may be an indication of deficiency (not of course complete) in the nerve supply to the unstriped muscle of the arterioles (which provide the muscle with blood). In cases of spastic paralysis this is not so, and therefore less care and caution is called for in treating these cases. Moreover, in such cases the muscle tone is exaggerated rather than diminished, even though the actual bulk of the muscle has diminished from lack of exercise, and thus the muscle in the walls of the arterioles is not subjected nearly so directly to pressure during massage.

Hence we see that in treating spastic paralysis we still aim at securing the same objectives, namely, to maintain nutrition and remove waste products, but that the danger now lies in inciting irritability in the muscle fibres by our manipulations. The most delicate stroking, picking-up, and possibly kneading over small areas, are therefore replaced by a firmer touch, as wide an area as possible being treated at the same time. The movement may be deep, but must be slow and even. Stroking should be firm, and a long sweep should be employed instead of the delicate movement of small amplitude advocated for the treatment of flaccid paralysis. The picking-up and kneading should be performed with the full grasp of as much of both hands as may be possible, instead of attempting to treat each minute section in turn.

In both flaccid and spastic paralysis treatment should aim at securing perfect mobility at all joints; but in flaccid paralysis every care must be taken never to stretch the paralysed muscle, whereas in spastic paralysis the difficulty will be to secure an adequate amount of movement without exciting spasm.

The value of massage in restoring muscular vitality has been proved experimentally by Zabludowski. He found that, when a muscle had been completely exhausted by repeated contractions in response to Faradism, subsequent rest had relatively little effect in restoring the power of contractility. After kneading, this power returned very swiftly, presumably because the waste products of muscular metabolism had been dispersed.

Moreover, Castex has shown microscopical evidence of the beneficent influence of massage on muscular tissue after injury. Lucas-Championniere thus epitomises the evidence: -

Similar injury having been inflicted by crushing, massage was applied to some cases, not to others. The latter showed: -

(i.) Dissociation into fibrillae of the muscular fibres, as shown by well-marked longitudinal striation; (ii.) A hyperplasia, sometimes a simple thickening, of the connective tissue; (iii.) An increase in places of the number of nuclei in the connective tissue; (iv.) Interstitial haemorrhages; (v.) An enlargement of blood-vessels, with hyperplasia of their adventitious coats; (vi.) The sarcolemma was usually intact, but, in one section, a multiplication of nuclei was seen, giving an appearance somewhat resembling an interstitial myositis. In the massaged limbs: - (i.) The muscle appeared normal; (ii.) No secondary fibrous bands separated the muscle fibres; (iii.) There was no fibrous thickening around the vessels; (iv.) The general bulk of the muscles was greater; (v.) There were no signs of haemorrhages.

In syringomyelia, as in progressive muscular atrophy, the masseur can often alleviate, though he cannot cure. By general massage of the deep-stroking and rhythmical kneading varieties it is possible to relieve the irregular pains and even perhaps to postpone the loss of thermal and tactile sensibility.

In the paralysis which follows an attack of acute poliomyelitis the muscles affected are perfectly flaccid. Treatment by mobilisation and massage should be commenced the moment pain and fever have abated. Delay is disastrous for two reasons: first, it is easier to prevent contractures than to cure them, and, second, while it is possible to keep any muscle fibres which will eventually recover properly nourished, the difficulty of the task is greatly increased once their vascular supply has been allowed to degenerate.

It is a well-known fact that, however complete the paralysis may seem to be at first, some return of power at a fairly early date is usually to be expected. In other words, the fibres are paralysed, not by disease of the nerve cells to which they owe their innervation, but because these cells are in close proximity to others which have suffered. It is possible that the cells are temporarily paralysed by the local inflammation around them.

Now we know that the "Saturday night paralysis" is rarely due (as a previous generation has thought) to pressure on the musculo-spiral nerve. It is usually to be attributed to falling asleep with the wrist resting in a position of extreme flexion. The forcible tension on the extensor muscles continued for only a few minutes, as anyone can test for himself, produces a decided weakening. This soon becomes more serious, and no great length of time need elapse to deprive the muscles altogether of their power of contraction.

The great danger run by a victim of poliomyelitis is that certain muscles which control a joint being unable to contract, the antagonists, by their natural tone, tend to stretch them. If the stretching of a healthy muscle can produce a complete paralysis, how much more can a similar effect be produced in a muscle which is deprived for the time being of its innervation! Every attempt should therefore be made from the outset to keep relaxed each muscle that is paralysed, and to prevent its antagonist from over-contracting. If this is done, massage can maintain nutrition until the time arrives when any nervecell, which has not been actually diseased, can resume its function.

In this way, and in this way only, can the part be kept in a condition which will enable the patient to recover power at the earliest moment and to the fullest extent. If relaxation is not secured from the outset, we have postural paralysis added to the real paralysis; and if massage is not employed, the nourishment of the muscle is not maintained, and wasting is rapid. Even granted postural treatment, the muscle fibres, supplied by the nerve fibres which survive, will, without the aid of massage, lack greatly in nourishment and, therefore, vitality.