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Reviewers
Carla M. Bashaw, BA, LMT Kevin Pierce, MBA, NCBTMB
Program Coordinator—Therapeutic Massage Academic Dean
Great Bay Community College East West College of Natural Medicine
Portsmouth, New Hampshire Sarasota, Florida

Robin Devine, RMT, CLT Rebecca Steele, RMT

Instructor Instructor
Massage Therapy Centre for Complementary Health Education
Mount Royal University Faculty of Continuing Education and Extension
Calgary, Alberta, Canada Mount Royal University
Calgary, Alberta, Canada
Luke Allen Fritz, LMT
Instructor
Health Enrichment Center
School of Therapeutic Massage and Bodywork
Lapeer, Michigan

Contributors and Reviewers to

Previous Editions
Wayne J. Albert, PhD, CK, FCSB
Sandra K. Anderson, BA, LMT, ABT, NCTMB
Patricia J. Benjamin, PhD
Paul V. Berry Jr., BSHA, LMT, NCTMB, PTA, NCMA
Leon K. Chaitow, ND, DO
Kelly Challis
Whitney Christiano, LMT, RYT, CPT, BA
Emily Edith Safrona Cowall, Reg, MT
Karen Craig, LMT, NCTMB
Neal Delaporta, LMT, NCTMB, CPT
Michael Garcia, RN, LMT
Peter A. Goldberg, DIPL AC (NCCA), LMT
MaryAnne Hochadel, PharmD, BCPS
Cher Hunter, MA, LMT, NCTMB
Christopher V. Jones, CMT, NCTMB
Don Kelley, LMT, NCBTMB
Kathy Lee, LMT, BS Business Administration
Lucy Liben, MS, LMT
Jean E. Loving, BA, LMT
Edward G. Mohr, MSIE, CPE, CSP, NCTM
Karen B. Napolitano, MS
Kathleen Maison Paholsky, MS, PhD
Kevin Pierce, LMT, MBA
Monica J. Reno, AAS, LMT
Richard Schekter, MS, LMT
Jeffrey A. Simancek, BS, CMT, NCBTMB
Cherie Marilyn Sohnen-Moe, BA
Diana L. Thompson, BA, LMP
Mary Margaret Tuchscherer, DC, PhD
Richard van Why
Sherri Williamson, LMT
Ed Wilson, PhD, LMT
Jeffrey B. Wood, LMT, COTA/L, BS

vi

Education, training, and skill standards define professions. If
massage professionals wish to be more widely recognized by
the general public and by other health care professionals, as
educated, professional, and well trained and with high stan-
dards, then they would do well to study and apply the knowl-
edge contained in this superb, newly revised, and expanded
book. Since the first edition in 1995, author Sandy Fritz has
emphasized critical thinking and clinical reasoning as the
foundation of the text. These skills are the cornerstone of
evidence-informed practice. The range of topics, and their
depth of exploration—combined with the unique, practical,
easy-to-follow delivery of information—makes it a universally
useful resource for anyone in the manual therapy professions
in general, and massage therapists in particular, and not just
in their early training stages. There is much to learn for expe-
rienced therapists since the author has focused on bringing
the very latest in clinical and practical research and under-
standing into the text.
The first four chapters build on each other, moving from
fascinating discussion of the multiple aspects of touch—the
fundamental element in massage—to chapters on profession-
alism, ethics, and standards, which go to the heart of what
is essential in defining any profession in the modern world.
This is followed by a description of protocols for the develop-
ment of a professional career. The evaluation of the multiple
steps and stages required to achieve the launch of a successful
career as a therapist is spelled out in excellent detail—with the
authority of someone who has done it all.
An essential part of professional practice is the ability to
accurately record what you have done and to be able to com-
municate your findings and treatment interventions to the
patient/client, to other health care professionals, or to those
responsible for reimbursement. Chapter 4 offers the founda-
tions for achieving this by focusing on terminology associated
with the systems of the body and therapeutic methods, as
well as record keeping, whether in simple SOAP notes or
electronically.
Chapter 5 is among the most important chapters in the
book as it eases the reader into the realm of research literacy.
Knowing what evidence there is for the use of particular thera-
peutic approaches, in specific settings, is a vital step on the
road to true professionalism—as is the need to know when
not to treat a person or a condition. A part of this demands
that you are able to read a research paper or an abstract, and
are able to see the key elements that might inform or modify
what you do, and how you do it in practice, as well as being
able to see when research evidence may be flawed. This is a
chapter to read and reread—and that advice applies to working
professionals as well as students, as we move toward evidence-
informed practice. Chapter 6 is a logical follow-up, since its
focus is on indications and contraindications to the use of
therapeutic massage—which quite naturally segues into clini-
cal reasoning—the very heart of the clinical decision-making
Foreword
process. What, how, and when to treat—or not—and when to
refer, and to whom!
Chapters 7 to 9 cover the detailed importance of hygiene,
sanitation, and safety, with that key word safety being the
main ingredient of Chapter 8. For if you wish to have a long
and successful career, it is vital that your own body is well
cared for, with attention to good body mechanics. There is no
finer teacher of this than Sandy Fritz. The number of thera-
pists who are obliged to abandon their careers due to overuse
and other results of poor use of their own bodies or hands is
a testament to the need for this subject to be taken very seri-
ously. Equally important are the topics regarding massage
equipment and supplies, as well as draping procedures, the
veritable nuts and bolts of a clinical practice, as covered in
Chapter 9.
Technical skills and protocols for delivery of professional
treatment—massage, manipulations, and techniques, includ-
ing seated and mat massage—are all fully illustrated in color
in Chapter 10, followed in Chapter 11 by a comprehensive
focus on assessments, tests, and analysis, which are all vital if
advanced approaches are to be developed. The sixth edition
provides a clear transition from foundational skills of mas-
sage therapy to a more client-centered professional practice.
Chapters 12 to 16 are organized into Unit IV, Beyond the
Basics. The complementary and adjunct methods associated
with massage are found in Chapter 12. Topics range from
hydrotherapy and myofascial approaches to an overview of
traditional Chinese medicine. These chapters also emphasize
adaptation of massage therapy to support an outcome-based
approach to professional practice. Chapters 13 and 14 focus
on special populations, exploring massage in a variety of set-
tings, such as spa and animal practices and adaptive massage.
Chapter 15 informs us how to pay personal attention to our
well-being as massage therapists—for it should be self-evident
that your professional life will be more successful and will last
longer if you remain fit! The wide range of case studies in
Chapter 16 allows you to tie together the mass of knowledge
covered so well in the rest of the book, woven into the context
of the most common problems encountered in a massage
practice.
This is a beautifully illustrated, well-thought-out, and struc-
tured expansion of the previous editions of this book, with a
host of new features, including Focus on Professionalism, Men-
toring Tips, and guidance for Learning More on the Web. For
more than 20 years, this textbook has evolved with and guided
the professional advancement of massage therapy. The author
and publishers are to be congratulated on producing it.
Leon Chaitow, ND, DO
Osteopath & Naturopath
Honorary Fellow
School of Life Sciences
University of Westminster
London
vii
Preface
Almost 40 years ago, when I was exploring a career in thera-
peutic massage, there were few schools. Because none of them
was readily accessible to me, I taught myself. I took a course
of less than 100 hours, which at least provided basic skills.
The rest of my massage therapy training has come from
reading a multitude of books, attending hundreds of hours of
workshops, undergoing apprenticeship training, taking college
courses in related subjects, teaching more than 5,000 begin-
ning students and approximately 1,000 advanced students at
my school, the Health Enrichment Center School of Thera-
peutic Massage and Bodywork, and providing more than
38,000 massage sessions. Since the publication of the first
edition, I completed my Bachelor’s degree at Central Michigan
University and Master’s degree at Thomas Edison State
College. Becoming a student again in the university environ-
ment had a great influence on my perspective about educa-
tion, as well as on my professional development.
I am still learning the importance of the fundamental con-
cepts upon which all bodywork methods are based. I learn
more about the elegant simplicity of massage each time I
teach or do massage, and I have learned a great deal through
researching and writing textbooks as well. More than ever, I
am convinced that a strong understanding of the fundamental
concepts of therapeutic massage and the ability to reason
effectively through a decision-making process are essential for
proficient professional practice. In the four decades of my
massage career, I have experienced an evolution of massage
therapy, from a fringe alternative method to the integration of
massage into the maturity of evidence-based and informed
practice. When I compare the first edition of this textbook to
this sixth edition, it is apparent that the knowledge necessary
to begin a massage therapy career has increased, yet the under-
lying fundamental principle remains—compassionate, benefi-
cial application of touch to help people feel better.
WHO WILL BENEFIT FROM THIS BOOK?
The sixth edition of Mosby’s Fundamentals of Therapeutic
Massage is intended to be used by skilled therapeutic massage
educators and beginning and advanced students in the class-
room setting. It will also be used as a continuing education
resource by practitioners and as a reference text for health
professionals and massage and bodywork practitioners.
WHY IS THIS BOOK IMPORTANT TO THE
PROFESSION OF MASSAGE THERAPY?
The changes and additions to the sixth edition reflect how
much therapeutic massage has evolved as a profession over the
past few years. Today, therapeutic massage is in the process of
standardizing and organizing. Projects such as the Entry Level
Analysis Program (elapmassage.org) and the Massage Therapy
viii
Body of Knowledge (MTBOK.org), an effort to unify the prac-
tice and terminology of massage and its various modalities,
attest to the growing awareness among massage professionals
that their success depends on clarity and an agreed-upon base
of knowledge, as in other skilled fields. It is an exciting time
in massage therapy, as we see more and more people turning
to massage as a reliable and practical form of self-care. A cur-
riculum that is mindful of all these points is a curriculum that
aims high.
A well-rounded education in massage therapy includes
learning all of the following: how to perform massage manip-
ulations and bodywork techniques; understanding the ana-
tomical and physiological underpinnings for why the methods
work in a biologically plausible and logical framework; and
the importance of structure, intent, and purpose of touch. It
is as important to touch the whole person as it is to skillfully
apply techniques. The massage professional must do both. In
addition, the learner needs to understand the importance of
sanitation, hygiene, body mechanics, research literacy, busi-
ness practices, and ethics, and then apply this knowledge
through effective decision making to build a well-balanced,
professional massage career. To justify the cost and time
spent, massage therapy needs to be beneficial and meet the
outcomes and results desired by the clients served. Massage
therapists need to be able to adapt to the individual client to
be successful.
The fundamentals of massage methods remain relatively
simple. Fundamentally, massage methods are mechanical
force push and pull applications. Certainly then there must
be more to massage therapy than just being able to give a
massage. A well-planned school curriculum, as developed in
this textbook and its instructor resources (TEACH Lesson
Plan Manual and instructor resources), combined with a
comprehensive science curriculum as presented in Mosby’s
Essential Sciences for Therapeutic Massage and its various
ancillaries, provides a foundation for massage educational
programs and presents information necessary for entry-level
licensing. With in-depth study, these textbooks also provide
the information and skill foundation for the advanced creden-
tial, the Board Certification Exam from the National Certifica-
tion Board for Therapeutic Massage and Bodywork.
Massage education should be competency based, meaning
all information in the educational setting is relevant to the
actual professional practice of therapeutic massage. The design
of this textbook, combined with the Evolve website, also sup-
ports various types of Web-enhanced education.
The level of knowledge in this sixth edition has been
increased to reflect the skills necessary to work effectively in
the health care world with supervision. Although my personal
love for this profession lies in humble service to the general
public in the support of their wellness, and compassion and
help for the daily aches and pains of life, I recognize the

importance of being able to also work within the health care
and sport and fitness systems. My work over the past several
years with a clinical physiologist, numerous physicians, ath-
letic trainers, and physical therapists supports this observa-
tion. Because of the development of comprehensive textbooks,
more schools will be better able to expand their curricula for
those who wish to pursue therapeutic massage applications in
health care.
The foundation for therapeutic massage was laid centuries
ago and will not change, provided human physiology remains
constant. It is virtually impossible to acknowledge all those
who have contributed to the knowledge base of this field. Our
observations of the natural world are a good starting point for
this basic knowledge. For example, animals know the value of
rhythmic touch. Just watch a litter of puppies or kittens and
observe the structured application of touch. The base of infor-
mation goes beyond us to an innate need to rub an area that
is hurting and to touch others to provide comfort, pleasure,
and bonding.
TEXTBOOK THEMES
These major themes guide the structure of this textbook.
• Massage therapy is an outcome-based approach targeting
the four main outcomes of relaxation and pleasure, stress
management, pain management, and functional mobility.
• Massage is based on three main approaches to care: pallia-
tive, condition management, and therapeutic change.
• Massage is uniquely adapted to every client based on goals,
assessment, special circumstances, client-centered inten-
tion, and compassion and nurturance.
• Massage is uniquely designed for each client based on
critical thinking, clinical reasoning, and evidence-informed
practice.
• Massage is a biologically plausible system based on applied
mechanical forces modified in multiple ways to both assess
the client and provide appropriate intervention to achieve
client goals.
• Massage is a professional health service provided in mul-
tiple environments and is dependent on the therapeutic
relationship between the massage therapist and the client.
TEXTBOOK ORGANIZATION
The textbook is divided into four units based on related
content.
Unit I: Professional Practice
1 Therapeutic Massage as a Profession
2 Ethics, Professionalism, and Legal Issues
3 Business Considerations for a Career in Therapeutic
Massage
4 Professional and Medical Terminology for Communica-
tion and Documentation
The chapters focus on building a solid basis for professional-
ism and decision-making skills before moving into the actual
physical and mental work of practicing massage. Chapter 1
Preface ix
begins with an exploration of touch and reveals its historical
foundations. Chapter 2 introduces the clinical reasoning,
problem-solving model for ethical decision making and also
explains what it means to be a professional, including aware-
ness of laws and regulations. Chapter 3 provides a newly
expanded look at the business of massage, job-seeking skills,
and the options of creating a career as a business owner or
as an employee. Chapter 4 presents appropriate medical and
massage therapy terminology to support professional record
keeping and documentation. Students are exposed to a lan-
guage that is understood across many disciplines and that
allows professionals to communicate accurately.
Unit II: Foundations for Massage Benefit
5 Research Literacy and Evidence-Informed Practice
6 Indications and Contraindications for Therapeutic Massage
7 Hygiene, Sanitation, and Safety
Massage therapy has become an evidence-informed practice.
Chapter 5 further explores what this means and explains the
scientific basis for evidence that supports the benefits of thera-
peutic massage. This chapter also focuses on research literacy,
empowering students to look deeper into their practice and
its value. Chapter 6 begins the process of decision making in
terms of indications and contraindications to massage.
Chapter 7 presents information on sanitation, hygiene, and
safety, ensuring the reader understands the importance of pro-
tecting the client from harm.
Unit III: The Massage Process
8 Body Mechanics
9 Preparation for Massage: Equipment, Professional Envi-
ronment, Positioning, and Draping
10 Massage Manipulations and Techniques
11 Assessment Procedures for Developing a Care/Treatment
Plan
Chapter 8 covers the very important content of body mechan-
ics and ergonomics. It is necessary for massage therapists to
be able to use their bodies effectively, efficiently, and wisely to
have a successful massage career. Chapter 9 describes massage
equipment and supplies, positioning and draping procedures,
various massage environments, and other information ancil-
lary to a successful massage practice. Chapters 10 and 11 focus
on technical skills. Each section builds on the previous one,
beginning with the basics and expanding assessment methods
to support therapeutic applications. As the methods and tech-
niques of therapeutic massage are presented, the reader learns
how and why they work and when to use them to obtain a
particular physiologic response. Upon completion of this unit,
the learner should be able to provide an outcome-based
massage.
Unit IV: Beyond the Basics
12 Complementary Bodywork Systems
13 Massage Career Tracks and Practice Settings
14 Adaptive Massage
x Preface
15 Wellness Education
16 Case Studies
Chapter 12 introduces the concept of adjunct methods, such
as hydrotherapy and essential oils. Massage application sys-
tems that have become specialized, such as lymphatic drain-
age, connective tissue, and myofascial release, and approaches
to treating trigger points are presented in the next section of
the chapter. An overview of Eastern and cultural approaches
based on traditional Chinese medicine, Ayurveda, and others
is covered in the next section. Reflexology is also included in
this content. Finally, a discussion on the adjunct methods
based on biofields (often called energy work) is provided, as
well as technical skill from the polarity system, which provides
a model for this type of bodywork.
Chapter 13 is a new chapter that focuses on three main
career tracks—wellness/spa, health care, and athletics. Chapter
14 describes how to adapt massage to address the needs rele-
vant to particular populations, from pregnant mothers and
infants to hospice patients and people with physical impair-
ments. Chapter 15 explores the issues of wellness and nutri-
tion. Massage therapy is a physically taxing field of work. An
MT must stay strong and healthy to do a good job and to
continue feeling rewarded by the work.
Finally, Chapter 16 sets the stage for putting the material
and your study to work through the use of comprehensive case
studies based on the clinical reasoning model, outcome-based
massage, and treatment plan development. This chapter pre­
sents 20 case studies that integrate the information from both
this textbook and the student’s science studies, such as those
covered in Mosby’s Essential Sciences for Therapeutic Massage.
The case studies cover the majority of common conditions
seen by massage professionals in day and destination spas, as
well as in wellness, health, fitness, sport, and medical settings.
If students study the process of clinical reasoning carefully,
these case examples will enable them to address almost all
other conditions encountered in professional practice. The
entire book focuses on developing clinical reasoning skills for
this profession.
Appendices
Helpful appendices are located at the end of the book.
These include an updated appendix on indications and
contraindications, a pictorial skin pathology appendix, as well
as a basic pharmacology for massage reference written espe-
cially for this textbook by a clinical pharmacist. All three
provide at-a-glance information that is supplemental to the
content within the chapters of the textbook.
AN ADAPTABLE DESIGN
It is not necessary to have multiple textbooks for each course.
Chapters in Mosby’s Fundamentals of Therapeutic Massage
can be used in multiple ways to provide content for courses
within the curriculum. The textbook can be taught in a
sequential manner from Chapter 1 to Chapter 16, or it can be
adapted to fit the order of topics within the chosen curricu-
lum. Another approach is to cluster the chapters into units as
previously described or modules such as the following:
• Chapters 1-4 as the professionalism and ethics unit
• Chapters 5-6 as the research literacy unit
• Chapters 7-12 as the guide on how to build massage appli-
cation skills
• Chapters 13-16 can then act as an integration unit.
Another organizational approach is as follows:
• Chapters 1-6 cover the practical and critical thinking skills,
which can simultaneously be taught with
• Chapters 7-12, so that the student learns hands-on skills
with thinking skills, all in a coordinated manner.
• Chapters 13-14 can be presented as practice specialization
content.
• Chapters 15-16 focus on integration of skills, such as clini-
cal experience. Chapter 15 (as well as many of the exercises
provided throughout the text) promotes introspection,
understanding, and topics that are supportive to the general
well-being of the therapist, and Chapter 16 offers a wide
variety of case studies.
When combined with Mosby’s Essential Sciences for Therapeu-
tic Massage, Mosby’s Fundamentals of Therapeutic Massage
provides a complete textbook resource for a relevant, accurate,
and outstanding massage therapy curriculum. Designed for
teachers and students by someone who is a teacher and
massage therapist, it is my hope that the textbook, all the ancil-
laries, and instructor support materials serve both teachers
and students in the journey of becoming extraordinary
massage therapy professionals.
Fritz Gives You the Fundamentals and More!
Welcome to the Sixth Edition
For content you can trust,
this text delivers:
CHAPTER OBJECTIVES
After completing this chapter, the learner will be able to
perform the following:
1. Identify personal interpretations of touch and their influence
on professional interactions
2. Describe professional touch
3. Explain the rich heritage and history of therapeutic
massage
4. Explain the influence of historical events and global culture
on the current development of therapeutic massage 1. The learner will be able to identify personal interpretations of touch
5. Self-assess for leadership qualities
Professional and Medical Terminology for Communication and Documentation
disabilities. Although the term intellectual disability is often
used in conjunction with developmental disability, many
people with a developmental disability do not have an
intellectual disability. Say she has cerebral palsy, he has
autism, or he has a developmental disability. Do not say she
is mentally retarded.
• Disfigurement refers to physical changes caused by burns,
trauma, disease, or congenital conditions. Do not say burn
victim. Say burn survivor or child who has burns.
• Down syndrome describes a chromosomal disorder that
causes a delay in physical, intellectual, and language devel-
opment. Say person with Down syndrome. Do not use
Mongol, mongoloid, or Down person.
• HIV/AIDS is a disease of the immune system. Over time,
HIV (human immunodeficiency virus) can weaken the
immune system to a point where the body becomes sus-
ceptible to certain illnesses that healthy immune systems
resist. People with HIV are diagnosed with AIDS (acquired
immunodeficiency syndrome) when one or more specific
conditions are met. Use person living with HIV or people
who have AIDS. Do not use AIDS victim.
• Intellectual disability refers to limitations in intellectual
functioning and adaptive behaviors that require environ-
mental or personal supports for the individual to live inde-
pendently. Although mental retardation was previously an
accepted clinical term, many consider it an insult, so people
who have this condition, their families, and related organi-
zations have campaigned to end its use. Say people with
intellectual disabilities. Do not use retarded, mentally
retarded, or subnormal.
• Learning disability describes a neurologically based condi-
tion that may manifest itself as difficulty learning and using
skills in reading (called dyslexia), writing (dysgraphia),
mathematics (dyscalculia), and other cognitive processes
due to differences in how the brain processes information.
Individuals with learning disabilities have average or above
average intelligence, and the term does not include a learn-
ing problem that is primarily the result of another cause,
such as intellectual disabilities or lack of educational
opportunity. Say person with a learning disability. Do not
use slow learner or retarded.
• Postpolio syndrome is a condition that affects some people
who have had poliomyelitis (polio) long after recovery
from the disease. It is characterized by new muscle weak-
ness, joint and muscle pain, and fatigue. Say person with
postpolio syndrome. Do not use polio victim.
• Psychiatric disability refers to a variety of psychological
conditions. Say person with a psychiatric disability or mental
illness. In a clinical context or for medical or legal accuracy,
use schizophrenic, psychotic, and other diagnostic terms.
Note, too, that bipolar disorder has replaced manic depres-
sion. Words such as crazy, maniac, lunatic, schizo, and psycho
are offensive and should never be applied to people with
mental health conditions.
• Seizure describes an involuntary muscle contraction, a brief
impairment, or loss of consciousness resulting from a neu-
rologic condition such as epilepsy or from an acquired
brain injury. Say girl with epilepsy or teen with a seizure
• Detailed and
competency-based
chapter and section
objectives.
PROFESSIONAL TOUCH
SECTION OBJECTIVES
Chapter objective covered in this section:
and their influence on professional interactions.
Using the information presented in this section, the learner will be able
to perform the following:
CHAPTER 4 151 • Distinguish between professional and nonprofessional forms of touch
disorder. The word convulsion should be used only for sei-
zures involving contraction of the entire body. Do not use
• List factors that influence the communication of touch
epileptic, fit, spastic, or attacks.
• Service animal or service dog describes a dog that has been
individually trained to do work or perform tasks for people
with disabilities. In addition to guiding people who are
blind, they may alert people who are deaf, pull wheelchairs,
alert and protect a person who is having a seizure, remind
a person with mental illness to take prescribed medica-
tions, or calm a person with posttraumatic stress disorder
during an anxiety attack. Miniature horses are also consid-
ered service animals under the Americans with Disabilities
Act (ADA), although monkeys no longer are. Do not use
seeing eye dog.
• Short stature describes a variety of genetic conditions
causing people to grow to less than 4′10′′ tall. Say person of
short stature, although some prefer little people. Dwarfism
is an accepted medical term but should not be used as
general terminology. Do not refer to these individuals as
midgets because of its circus sideshow connotations.
• Speech disability is a condition in which a person has
limited or impaired speech patterns. Use child who has
a speech disability. For a person without verbal speech
capability, say person without speech. Do not use mute or
dumb.
• Spinal cord injury describes a condition in which there has
been permanent damage to the spinal cord, resulting in
some degree of paralysis. Quadriplegia denotes loss of
function in all four extremities, whereas paraplegia refers
to loss of function in the lower part of the body only; in
both cases the individual might have some function in the
affected limbs. Although people with spinal cord injuries
often refer to themselves as a para or a quad, communica-
tors should use man with paraplegia, woman who is para-
lyzed, or person with a spinal cord injury. Don’t say cripple
or handicapped.
• Substance dependence refers to patterns of substance use
that result in significant impairment in at least three life
areas (family, employment, health, etc.) over any 12-month
period. Although such terms as alcoholic and addict are
medically acceptable, they may be derogatory to some indi-
viduals. Acceptable terms are people who are substance
dependent or person who is alcohol dependent. Individuals
who have a history of dependence on alcohol and/or drugs
and are no longer using a substance may identify them-
selves as recovering or as a person in recovery.
• Survivor is used by people to affirm their recovery from or
conquest of an adverse health condition such as cancer
survivor, burn survivor, brain injury survivor, or stroke sur-
• ELAP and MTBOK knowledge, skills, attitudes,
vivor. Don’t call them victims.
Additional terms related to the Americans with Disabilities
Act (ADA):
• Accessibility: describes the degree to which an environ-
ment, service, or product allows access by as many people
and terminology content.
as possible, in particular, people with disabilities.
• Accessibility standards: a standard is a level of quality
accepted as the norm. The principle of accessibility may be
mandated in law or treaty and then specified in detail
xi
 Therapeutic Massage as a Profession CHAPTER 1 3

FIGURE 1-3 Novel repetition can be seen and heard in music, for
example.

eventually teaching you to become your own teacher to

FIGURE 1-1 Spiral learning.
2 massage therapy?
3
4 tions mentioned previously are explored in this text, especially
FIGURE 1-2 Straight-line learning.
begins to ignore the information because it is too familiar
(Figure 1-2).
Repetition is absolutely necessary to learn anything.
However, to keep the brain interested, the repetition somehow
must be different each time. Think of a piece of music. You
can hear the repetition of a melody in a few lines of music,
but you can also hear where the composer has changed a note
or two. You enjoy hearing the repetition of a good melody, but
you also enjoy when it is changed slightly, because this pre-
vents you from becoming bored with it. This is called novel
repetition (Figure 1-3); that is, the same information is given
over and over, but always a little differently and in a circular
format. As you learn the profession of massage, this type of
repetition eventually spirals into the ability to become a cre-
ative and skilled massage therapist. As you read and study this
textbook, notice how learning spirals, novel repetition, and
asking questions are teaching you to use critical thinking and
support lifelong learning.
In massage, which is professional, structured, therapeutic
touch, education begins with questions.
• What is the significance of touch?
• What is professional touch?
• What motivates me to study therapeutic massage?
• What is therapeutic?
• How am I served by touching others?
• When did touch become professional?
• Why did touch become professional?
• Do therapeutic forms of touch have to be provided by a
professional?
• In what way is professional therapeutic touch different
from casual touch, friendship touch, family touch, intimate
touch, or erotic (sexual) touch?
• How do different individuals, social groups, or cultures
view touch?
• In what way does the past affect the present and provide
guidance for the future development of the profession of
Questions continue to arise, and the answers are not neces-
sarily simple. As we seek to serve our clients, eventually we are
faced with these questions and many others. Some of the ques-
as they relate to the professional practice of therapeutic • ONGOING AND EXPANDED emphasis on
critical thinking and clinical reasoning
massage. Some are not explored directly; rather, both the
questions and the answers evolve for each learner as the indi-
vidual’s information base and experience increase and the
journey through education continues. This text does not
provide definitive answers to any of these questions; however,
skills development.
it does provide information to help you find your own answers
to questions you may face.
• UPDATED Chapter 5: Research Literacy
What will your questions be? How will your answers influ-
ence those you touch? How will your answers touch you? and Evidence-Informed Practice, which
These are huge issues to consider at the beginning of any
course of study. As you begin to think about them, you might focuses on the expanding role students
can play in learning more about the
feel interested, excited, overwhelmed, or maybe even fright-
ened as you come to realize how necessary, beneficial, complex,
and powerful touch can be. Remember that understanding
evolves. These important questions are posed at the beginning
of this study and possibly before you have sufficient informa-
growing body of science within the
tion to develop effective answers. Your awareness of these
questions will help you make decisions and find answers as
massage field.
you progress in your study of therapeutic massage.
You will come to understand the process of developing
your answers to the previously mentioned questions and
many others that will arise by embracing the importance of
respect—not only for yourself but also for all those with 210 MOSBY’S FUNDAMENTALS OF THERAPEUTIC MASSAGE

• Direction involuntary response to a stimulus, and massage can be the

• Drag source of the stimulus.
• Speed The problem with this simple categorization is that the
• Pacing mechanism by which massage produces an effect cannot
• Rhythm always be clearly identified. According to Dr. Philip E. Green-
• Sequencing and transitioning man, the effects of massage occur through the interrelation-
• Spiral approach to learning is • Frequency
• Duration
ships of the peripheral nervous and central nervous systems
(and their reflex patterns and multiple pathways), the auto-
embedded where first the basic • Intention for outcome
Adapted methods generate appropriate force to load the
nomic nervous system, and neuroendocrine control (Green-
man, 2003). Dr. John Yates (1990) has said, “It appears far
facts of a subject are presented. As body tissue in order to create 5 stresses to which the physiol-
ogy must adapt:
more reasonable just to recognize that massage produces
effects that are due to a combination of mechanical, neural,

the learner progresses through the • Compression stress

• Tension stress
chemical, and psychological factors and to identify these
wherever possible rather than to attempt to use them as a basis

textbook, the basic content is

• Shear stress
• Torsion stress
• Bending stress
reinforced, expanded, and framed The techniques of therapeutic massage and other types and
styles of bodywork are merely variations of the fundamental
in increasingly more complex ways, application of manual manipulations. The benefits of the
techniques are simply the result of basic physiologic effects. It
which supports critical thinking and is helpful to have a method for categorizing information into
similar bundles. By doing this, we can take many large pieces
for classifying those effects.”
To understand the basis of research findings, we must
understand the biologically plausible mechanisms by which
massage applications achieve benefits. This understanding is
grounded in the study of functional anatomy and physiology
as they relate to therapeutic massage. The recommended text
for this purpose is Mosby’s Essential Sciences for Therapeutic
Massage: Anatomy, Physiology, Biomechanics, and Pathology, by
Sandy Fritz.

content retention. of information and sort them into manageable sizes. This
process helps with the clinical reasoning process used to make
sense of information and to make decisions about what to do
with the data. The problem with this method is that most
things do not clearly fit into one category or another, and often
the result is not entirely accurate. However, as long as we
understand this, we can make use of the process.
A premise of massage application is to mimic and support
normal function. The anatomic and physiologic areas most
targeted by massage are:
• Nervous/neuroendocrine system (the central, auto-
nomic, and somatic nervous systems, in addition to
neurochemicals and hormones)
• Circulation
• Connective tissue

Physiologic Effects
As stated previously, conclusive research on the physiologic
effects of massage is lacking. The following sections present
theories—not facts—about how massage works. A theory
presents a concept or idea that is testable. In science, a theory
is not merely a guess. A theory is a fact-based framework
for describing a phenomenon. The problem in massage
therapy is that not enough research has been done on the
theories, and because research is very expensive and time-
consuming, it may be quite a while before this situation
changes.
The fundamental concepts that explain the effects of thera-
peutic massage can be divided into two general categories,
mechanical effects and reflexive effects.
• Mechanical effects occur when a mechanical force (push
or pull), which creates mechanical stress (tension, bending,
shear, torsion, and compression), is applied directly to the
body and directly affects the soft tissue through techniques
that normalize the connective tissue or move body fluids
and intestinal contents. Myofascial tissue (muscle and its
associated connective tissues) and fluid content determine
the density and pliability of a muscle structure.
• Reflexive effects occur when various mechanical forces are
introduced into body tissues during massage with the
intent to stimulate the nervous system, the endocrine
system, and the chemicals of the body. A reflex is an
TRANSLATING EVIDENCE INTO
PRACTICAL APPLICATION: NERVOUS/
NEUROENDOCRINE SYSTEM
SECTION OBJECTIVES
Chapter objective covered in this section:
7. Explain the effects of therapeutic massage in physiologic terms.
Using the information presented in this section, the learner will be able
to perform the following:
• Explain the possible anatomic and physiologic influences of massage
on the neuroendocrine system
Effects of Massage on the Nervous System
The body’s responses to massage and its effects on the nervous
system are primarily reflexive.
Briefly, the nervous system is divided into the central
nervous system (CNS), which consists of the brain and the
spinal cord and its coverings, and the peripheral nervous
system (PNS), which consists of nerves and ganglions (Figure
5-5). The PNS is further divided into the autonomic and
somatic divisions. The autonomic nervous system (ANS)
division is subdivided into the sympathetic and parasympa-
thetic systems. The sympathetic system is responsible for
functions that expend energy in response to emergency or

xii

Massage Equipment
Massage Table
Massage therapists typically work in the standing position.
Therefore the width and height of the massage table deter-
mine the postures the therapist uses. Massage therapists are at
higher risk of cumulative episodes of pain in the low back and
upper extremities if they are required to maintain awkward,
static postures for the duration of a massage treatment.
The massage table can cause these awkward postures in three
main ways:
• If the table is too low, the therapist may be required to
slouch and bend over. In this case the table should be
raised.
• If the table is too high, the therapist may have to elevate
the shoulders, use lateral flexion and twisting of the torso,
and stand on the toes. The solution is to lower the table.
• If the table is too wide (or the massage stroke is too long),
the therapist must reach. The solution is to use a narrower
table, shorten the strokes, and step forward and perpen-
dicular to the massage table.
Ideally the table height could be varied according to the
technique used and the client’s size. However, this is seldom
actually possible. Although electric-lift adjustable massage
tables are becoming more common, they are not portable.
Many textbooks state that the proper working height of a table
is equal to the distance from the floor to a point between the
therapist’s wrist and the tips of the extended fingers (or about
the middle of the hand) when the arm is hanging at the side
of the body. However, some suggest that occasionally the
optimal height may be as low as the therapist’s knees or as
high as the waist (Figure 8-2).
According to the Canadian study by Albert et al. (2006)
mentioned earlier, the average fingertip height is 38% of a
person’s stature. Interestingly, the massage therapists in this
study all chose table heights that were 40% to 43% of their
standing height, which would be between the fingertips and
wrist, as suggested in their training manuals. The study found
that on average, trunk postures were divided 50-50 between
the neutral position category and the mild posture distortion
category; the shoulder and neck were in neutral postures for
30% and 40% of the time, respectively. Obviously, these table
heights resulted in an inappropriate workstation.
Punnett et al. (1991) found that the risk of back disorders
increased significantly with time worked in nonneutral pos-
tures and that the risk increased further when a nonneutral
posture (meaning some sort of twisting) was used in more
than one of the principal axes at a time.
The posture categories reported in the study by Albert et al.
(2006) mirrored those of Punnett, and the significant working
time in a mild trunk flexion reported for the massage thera-
pists is reason for concern. The trunk postures required of the
massage therapists in this study would result in significant
cumulative loads for a 45- to 60-minute massage. These find-
ings indicate that the massage therapists were flexing forward
to do massage; therefore, the massage table was too low, and
raising the height of the table would be logical. The massage
table must be kept at a comfortable height, which depends on
• Comprehensive content revision
based on new developments in
the massage therapy field.
Body Mechanics CHAPTER 8
Box 8-2 Massage Equipment Ergonomics
Working with a Massage Table
• As a general rule, the table height should be one half the
practitioner’s height. Therefore, if the practitioner is 5
feet, 6 inches tall (66 inches), the table should be
approximately 33 inches high.
• Depending on the therapist’s torso, arm, and leg length
ratios, the correct height for the table will be 2 to 3
inches higher or lower. An individual with long arms may
need a shorter table than a person with short arms. A
person with a short torso, short arms, and long legs
often needs a taller table.
• Typically a woman needs a taller table than a man of the
same height.
• A table 24 to 28 inches wide provides adequate space
for the client to lie down comfortably, but it is not so
wide that the therapist must reach for the client in the
middle of the table.
• The knees and hips are used to lift portable tables. The
therapist should not bend forward at the waist when
lifting the massage table. Some tables have shoulder
straps, wheel bases, and other devices to aid in
transport by redistributing the weight load.
• Consistently carrying the table on only one side of the
body may be harmful. Alternate carrying arms; for
example, carry in with the left arm, carry out with the
right.
Working on a Floor Mat
• Body mechanics similar to those used for working with a
table apply for working on a mat on the floor. The
notable difference is that the center of gravity is lower,
necessitating greater core strength.
• Movement around the client is different when the person
is on a floor mat rather than a massage table. The
weight-bearing balance points on the floor are from the
knees instead of the feet.
• Padding on the knees may be required. Kneepads are
available.
• The mat must be large enough so that the massage
therapist can keep his or her knees on the mat while
doing the massage.
Working with a Massage Chair
• Specially designed massage chairs help with positioning
the client so that compression can be applied correctly.
Regardless, prolonged use of a massage chair to deliver
massage strains the massage therapist’s body.
the practitioner’s height, the client’s size (thick or thin), and
the style of massage used (Box 8-2).
Awkward posture is associated with an increased risk for
injury, and the more a joint deviates from the neutral position,
the greater the risk of injury (Box 8-3). Every joint in the body
has a neutral position, in which joint spaces are even and sym-
metric (Box 8-4). The muscles around a joint in neutral posi-
tion are neither short nor long, but rather at their neutral
physiologic resting lengths. Joint stability is provided with the
least amount of muscle activity and maximizing stability
• Chapter 8: Body Mechanics, which takes
301
a closer look at adapting massage
application based on body shape and
gender. Therapeutic massage is a
physically labor-intensive therapy that
requires time to perform, with an
emphasis on ergonomics and correct
body mechanics. The sixth edition has
expanded coverage of this information,
and new content has been evaluated by
ergonomics experts.
654 MOSBY’S FUNDAMENTALS OF THERAPEUTIC MASSAGE
for cancer. Palliative care is aimed at relieving suffering and
improving quality of life in patients undergoing treatment
for the primary condition. Such care addresses physical symp-
toms, such as pain, shortness of breath, and nausea, but
also nonphysical causes of pain, such as sadness, depression,
and anxiety. Palliative care is not the same as hospice, which
provides end of life care for patients who no longer want
to pursue more aggressive therapy. A major priority of pallia-
tive care is to incorporate the principles of palliative care
into the care of all patients with cancer from the time of
diagnosis, not only in the setting of advanced or terminal
disease. Palliative care focuses on the whole person, encom-
passing body and mind to enhance comfort and preserve
dignity.
Therapeutic Massage Strategies During
Cancer Treatment
Massage is accepted as part of a multidisciplinary approach to
cancer treatment. The benefits of massage are obvious: stress
management, preoperative and postoperative pain manage-
ment, management of treatment side effects, and more. There
are no specific protocols for massage and cancer care. The
person undergoing cancer treatment must be evaluated each
session, and the massage treatment must be based on the
individual’s status at that time.
The concern that massage increases metastasis is unfounded.
However, it is prudent not to massage over any type of tissue
masses. Specific, extensive, full-body lymphatic drainage may
task already compromised immune function and should not
be used. The areas of radiation treatment need to be avoided,
because the skin is damaged by the treatment.
Caution:
• Avoid all sources of heat (hot water bottles, heating
pads, and sun lamps) on the treatment field.
• Avoid exposing the treatment area to cold temperatures
(ice bags or cold water treatment).
• Avoid any form of saltwater treatment.
• Avoid the use of all lotions or oils on the skin in the
treatment field and use only approved lotion during
massage.
• Avoid direct massage of the treatment area, other than
light application of approved lotion (Lewis et al., 2006).
Bones under areas of radiation treatment can be brittle;
therefore, massage pressure levels need to be monitored care-
fully. Do not use any massage methods that may cause tissue
damage because chemotherapy reduces the body’s ability to
repair tissues. The general protocol may be too intense during
cancer treatment, but the modified, palliative protocol (dis-
cussed later in the chapter on page 655) can be used as an
appropriate starting point for massage and then adapted spe-
cifically for each client.
Key Points
• Cancer treatment can be curative or palliative.
• Massage as part of an oncology treatment plan targets pal-
liative care as part of symptom management, especially the
side effects of treatment.
• Survival rates for cancer patients are steadily increasing as
a result of early detection and advances in treatment.
• Cautions for massage typically arise from changes in the
client’s skin as a side effect of treatment.
• Caution is necessary for fatigue and limits in adaptive
capacity.
HOSPITAL, LONG-TERM CARE,
AND HOSPICE PATIENTS
SECTION OBJECTIVES
Chapter objective covered in this section:
10. Adapt massage for integration into the various medical settings.
Using the information presented in this section, the learner will be able
to perform the following:
• Explain the importance of comfort measures
• Adapt massage application based on the circumstances of
hospital care
• Adapt massage application for individuals in long-term
medical care
• Define hospice care
• Adapt massage for end of life care
Use of massage therapy in hospitals is becoming more common. Some
of the reasons it is used include:
• Pain management
• Relief for cancer patients
• Pregnancy massage
• Adjunct to physical therapy
• Mobility/movement training
• Palliative care
A common theme in hospital-based massage is pain man-
agement. Massage is effective at managing acute and chronic
pain and supports other pain treatments, such as medica-
tion, ultrasound, and hydrotherapy. As mentioned, although
massage targeting pain reduction commonly is thought of as
therapeutic change, in reality it is palliative (see Chapter 6).
Massage for the hospital patient is not targeted specifically to
the pathologic condition or injury; rather, it is intended to
provide comfort care and symptom management (Box 14-8;
also see Box 14-7).
Benefits of Massage for
Box 14-8
Hospital Patients
1. Pain: Through the use of massage, the subjective
experience of pain is diminished, even when the use of
analgesics is reduced.
2. Anxiety: Anxiousness caused by the hospital stay and
fear of procedures is reduced.
3. Nausea: The subjective experience of nausea and the
use of antiemetics are reduced.
4. Stress: Physiologic indicators of stress (e.g., raised
cortisol level) are diminished, and indicators of reduced
stress (e.g., improved serotonin level) are increased.
5. Sleep: The ability to sleep more easily and for longer
periods increases with massage.
xiii
 Features and activities that
motivate and make you think
PROFICIENCY EXERCISE 10-2
1. Inflate a series of balloons with different internal
pressures. Fill some with water and others with gelatin
and use these to represent the density and pliability of
different tissue types. Balloons are great for practicing
the angle and pressure of the manipulation. The best
angle allows good, firm compression into the balloon
without it slipping out from under you.
2. Use pieces of foam of various densities and place them
over objects of different sizes and shapes. Determine
how much pressure it takes to feel each object. Pay
attention to the difference between the low-density foam
and the high-density foam.
3. Design a complete massage using only compression.
Pay very close attention to ways in which you can use
compression techniques to access the client’s body
successfully. Adjust depth of pressure, speed, rhythm,
frequency, and duration and observe the different
physiologic effects. Have a client lie on a mat and
experiment with using your leg and foot to apply
compression.
Visuals that guide
A B
D E
FIGURE 10-28 Examples of percussion. A, Hacking. B, Cupping. C, Fist beating. D, Beating over the palm. E, Slapping.
tapping.
xiv
• Reality-based examples embedded
throughout the textbook, helping readers
understand content.
effect on the nervous system, it initiates or enhances
sympathetic activity of the autonomic nervous system. The
effects of the manipulations are reflexive. However, percussion
also can have mechanical results, which involve loosening
and moving mucus in the chest. People with cystic fibrosis
are treated with percussion, but massage therapy of this
type is beyond the beginning skill levels of the massage
therapist.
The most noticeable effect of percussion results from the
response of the tendon reflexes. A quick blow to the tendon
stretches it. In response, protective muscle contraction occurs.
To obtain the best result, stretch the tendon first. The most
common example of this reflexive mechanism is the knee-jerk
(or patellar) reflex, but this response happens in all tendons to
some degree. This is very helpful when the massage therapist
is preparing the muscles for elongation applications, such as
when a client indicates that the hamstrings are tight and need
to be lengthened. With the client supine, the hip flexed to 90
degrees, and the knee flexed to 90 degrees, percussion on the
stretched quadriceps tendon causes the quadriceps to contract.
As a result, the hamstrings are inhibited, which makes them
easier to lengthen to a more normal resting length.
When applied to the joints, percussion affects the joint
kinesthetic receptors responsible for determining the position
and movement of the body. The quick blows confuse the
system, similar to the effect of joint-focused rocking and
shaking, but the body muscles are stimulated rather than
inhibited. This method is useful for stimulating weak muscles.
The force used must move the joint but should not be strong
enough to damage it. For example, a single finger may be used
to administer percussion over the carpal joints, whereas the
fist may be used over the sacroiliac joint.
Percussion is very effective when used at motor points that
usually are located in the same area as the traditional acupunc-
ture points which in turn are located at neurovascular bundles.
C The repetitive stimulation causes the nerve to fire repeatedly,
stimulating the nerve.
Percussion focused primarily on the skin affects the
superficial blood vessels of the skin, initially causing them to
contract. Heavy percussion or prolonged lighter application
dilates the vessels by causing the release of histamine, a
vasodilator.
Applying Percussion
Two hands usually are used alternately to do percussion. One
or two fingers can be used to tap a motor point located at the
center of the muscle mass where the motor nerve enters the
muscle (this sometimes is called neurotapping). The forearm
muscles contract and relax in rapid succession to move the
elbow joint into flexion and then allow it to release quickly.
This action travels down to the relaxed wrist, extending it; the
wrist then moves back and forth to provide the action of the
percussion. Percussion is a controlled flailing of the arms as
F the wrists snap back and forth. Remember that the wrist must
always stay relaxed. Beginning students usually want to use the
wrists to F, Finger
provide the snap action. This is especially tempting
when using small movements of the fingers; however, it will
damage the wrist.
Massage Manipulations and Techniques CHAPTER 10 381
Heavy percussion should not be done in the kidney area or
anywhere pain or discomfort is present. The following are
methods of percussion (Figure 10-28).
• Hacking. Hacking is applied with both wrists relaxed and
the fingers spread, with only the little finger or the ulnar
side of the hand striking the skin surface. The other fingers
hit each other with a springy touch. Point hacking can be
done by using the fingertips in the same way. Hacking is
done with the whole hand on the larger soft tissue areas,
such as the upper back and shoulders. Point hacking is used
on smaller areas, such as the individual tendons of the toes,
or over motor points.
• Cupping. To perform cupping, the fingers and thumbs
are positioned as if making a cup. The hands are turned
over, and the same action used in hacking is performed.
When done on the anterior and posterior thorax, cupping
is good for stimulating the respiratory system and for
loosening mucus. If the client exhales and makes a mono-
tone noise during cupping, enough pressure is used
so that the tone begins to break up, changing from
“AAAAAAAAAAAAHHHHHH” to “AH AH AH AH AH
AH”.
• Beating and pounding. These moves can be performed
with a soft fist with the knuckles down or with the fist held
vertically and the action performed with the ulnar side of
the palm. This technique is used over large muscles, such
as the buttocks and heavy leg muscles.
• Slapping (splatting). For this technique, the whole palm of
a flattened hand makes contact with the body. This is a
good method for causing the release of histamine, thereby
increasing vasodilation and its effects on the skin. It also is
a good method to use on the bottoms of the feet. The broad
contact of the whole hand disperses the force laterally
instead of downward, and the effects remain in the
superficial tissue. Kellogg (2010) called this movement
splatting.
• Tapping. For this technique, the palmar surface of the
fingers alternately taps the body area with light to medium
pressure. This is a good method to use around the joints,
on the tendons, on the face and head, and along the spine
(Proficiency Exercise 10-8).
PROFICIENCY EXERCISE 10-8
1. Play a drum or watch a drummer. Pay attention to the
action of the arms and wrists and the grasp of the
drumsticks. Notice that the drummer holds the
drumsticks loosely.
2. Get a paddleball or yo-yo and see what actions it takes
to make these toys work. Play with a rattle or tambourine.
3. Use the foam from the compression exercises and
practice the different methods and intensity of percussion
(light to deep, slow to fast).
4. While shaking your hands very quickly, use hacking to
strike the foam or a practice client. Without stopping,
change hand positions so that all the methods are used.
5. Design a stimulating massage with various applications
of percussion. Notice which qualities of touch are most
reflected with these methods.
• UNIQUE TO THIS TEXT: The final chapter
in this book contains 20 case studies
that help the student to appreciate the
complexities of a therapeutic relationship,
all in a competency-based format.
FOCUS ON PROFESSIONALISM 1-1
The actions of every massage therapist affect the massage
profession as a whole. There is an expectation of behavior
when one claims to be a massage therapist. Behaviors include
appearance, speech, actions, and advancement of knowl-
edge and skills through lifelong learning. As professionals we
need to walk the talk. Each of us has a responsibility to the
entire massage community. When a professional, we have to
always act as a professional even during personal time if in
public view. Social media is an example of when the profes-
sional commitment can be confused. If a posting to social
media does not comply with accepted and expected profes-
sional behavior, especially when directly related to massage
therapy, the conduct could be considered unethical. For
example, it is very unprofessional when a picture of a massage
therapist in revealing clothing or discussing involvement in
questionable behavior such as driving under the influence of
alcohol is included with posts about massage appointment
availability. Think about it.
696
MOSBY’S FUNDAMENTALS OF THERAPEUTIC MASSAGE
CASE 2. MUSCLE TENSION HEADACHE
A 26-year-old woman is in good health except for frequent
headaches that radiate pain from the back of her skull around
her ears and over her eyes. Migraine and cluster headaches
have been ruled out. The diagnosis is muscle tension head-
aches. Because no medical reason has been found for the
headaches, they are assumed to be related to stress. They do
not follow any cyclic pattern. A relationship to the menstrual
cycle has not been indicated.
The client has a temporary job as a waitress while she fin-
ishes college. She spends a lot of time sitting, reading, and
working at the computer. She notices increased tension in her
neck, shoulders, and lower back when she has to spend a lot
of time with her studies. She swims three times a week for
exercise and is careful with her diet. She has a moderate intake
of caffeine and alcohol, and she smokes. She is not under any
medical care.
Because common over-the-counter analgesics such as
aspirin and acetaminophen bother her stomach, she is seek-
ing an alternative to manage the pain. She has tried chiro-
practic care, with limited success, and often experiences a
headache right after an adjustment. She has heard that mas-
sage can help these types of headaches. A friend referred her,
indicating that she would be comfortable with a middle-aged
female therapist with a home-based practice. The client has
completed an informed consent process and has agreed to
treatment.
Assessment
Observation
The client is nearsighted and wears glasses. She repositions her
glasses often, and she squints in the bright light. She is polite
and soft-spoken. She appears frustrated and tired of the
inconvenience of the headaches. She is neatly groomed and
very organized; she provides a list of all the treatments that
have been tried for the headaches, including a food diary and
schedules attempting to identify the cause of the headaches.
Her weight is normal for her height. She has long, thick hair
that she wears in a ponytail.
Interview and Goals
The client’s history reveals that she has had headaches for as
long as she can remember. She has a headache severe enough
to interfere with daily activities about 10 days out of a month.
The headaches last about 12 hours, and the pain is a 7 on a
scale of 1 to 10 (1 being slight, 10 being extreme). She does
not remember any injury or surgery or any childhood diseases
other than the normal ones. She had the headaches during
adolescence. She generally ignores the headaches, but they are
becoming draining. The family history provides no insight.
There is a family history of cancer. She wore braces for 3 years
and recently had them removed. She has worn glasses and has
had long hair since her early teens. She admits to being a
perfectionist.
Her goals for the massage are to reduce the frequency and
intensity of the headaches.
• NEW FOCUS ON PROFESSIONALISM feature
throughout the text that reinforces the importance
of professional and ethical behavior.
Physical Assessment
Posture
No obvious postural asymmetry.
Gait
No obvious gait distortions.
Range of Motion
Slightly limited in all directions in the neck with moderate
reduction of capital flexion. Temporomandibular joint (TMJ)
opens only to two fingers’ width (three is normal).
Palpation
Near Touch. Neck near the occipital base and the lower
back are warm.
Skin. All areas are normal except for goose bumps and
dampness at the occipital base and lower back. Tissue texture
is symmetric and normal. Unable to lift a skinfold over the
entire length of the spinal column.
Superficial Connective Tissue. Superior and inferior binding
of connective tissue is present at the occipital base, sacrum,
forehead, and calves.
Vessels and Lymph Nodes. Normal
Muscles. Tender points are noted in the masseter, frontalis,
temporalis, and occipital base muscles. Moderate pressure on
these points results in pain that mimics the headaches. Neck
extensors are short and tight. Surface muscle tone seems gen-
erally high. Calf muscles are tight and short bilaterally.
Tendons. Normal
Deep Fascia. Fascia from the skull to the sacrum binds.
Scalp is tightly bound to the skull.
Ligaments. Normal
Joints. TMJ palpates tender to mild pressure and has
reduced range of motion.
Bones. Normal
Abdominal Viscera. Normal
Body Rhythms. Rhythmic but fast
Muscle Testing
Strength
Normal except that head and neck extensors are overly strong.
Head and neck flexors are inhibited.
Neurologic Balance
Tonic neck reflexes and eye-righting reflexes are overactive;
consequently, limb and back extensors do not inhibit when
client looks down toward navel.
Gait
Normal except that head seems to be held stiffly when client
walks.
Interpretation and Treatment Plan Development
Clinical Reasoning
What Are the Facts?
Muscle tension headaches are a common and recurring
problem for many people. They are benign, although all other
xv

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expand on selected content. The information and
links guide the reader in exploration of the many
helpful resources from a variety of U.S. government
and affiliated agencies, nonprofit organizations, and
sources for valid research.
LEARN MORE ON THE WEB
MEDLINEPLUS is one of the most useful websites for
massage therapists and massage therapy students
interested in learning more about the techniques described
in this chapter. Visit the site and use the search term burns,
hydrotherapy, and hot stone massage, for example. The U.S.
Food & Drug Administration has some content on essential
oils, and the EVOLVE site provides links to articles related to
connective tissue and aromatherapy.
• UPDATED workbook sections that are
also available in an e-format on Evolve.
xvi
• NEW MENTORING TIP feature from the experiences
of the author to promote introspection and
classroom discussion.
MENTORING TIP 10-1
It is unclear how various massage manipulations and tech-
niques specifically affect the physiology to provide massage
benefits. Research has provided clues, and we can make
educated guesses, but we do not know the exact mecha-
nisms of how massage helps us feel and do better. For each
massage method in this chapter, there is a description, theo-
ries of effect, and instruction in how to apply the methods.
The description reflects the Entry Level Analysis Project and
Massage Therapy Body of Knowledge content. The theories
of effect are biologically plausible and justifiable based on
what we do know about massage. The instructions about
application are consistent with historical data and reflect
current recommendations by experts. It is difficult to reach a
consensus because there are so many different opinions and
ideas about massage. Learn from this textbook, your instruc-
tors, your classmates, and yourself. There is no absolute right
or wrong way to give a massage, as long as no harm is done
and safety is a priority for both you and the client.
28
Workbook Section All Workbook activities can be done electronically online
as well as here in the book. Answers are located on Evolve.
Review Questions _____ 19. Margaret Knott and Dorothy Voss
_____ 20. Esalen and Gestalt
Write your personal definition for each of the following words.
_____ 21. Autonomic approach
1. Professional
_____ 22. Mechanical approach
_____ 23. Dr. Boris Chaitow and Dr. Stanley Lief
_____ 24. Dr. Milton Trager
_____ 25. Ronald Melzack
2. Structured
_____ 26. ELAP
a. Proposed an integrated program of active and passive
movements based on Swedish gymnastics
b. Systems based on lines and points
3. Therapeutic
c. Developed Rolfing
d. Divided the effects of massage into two categories:
mechanical actions and reflex actions
e. Founded bioenergetics
4. Touch
f. Inspired psychotherapists to explore massage and
movement therapies
g. Changes abnormal movement patterns into optimal
ones
Essay Questions h. Used French terms such as effleurage and pétrissage
i. An English physician who studied directly with Ling
1. What does “touch intention” mean to you? and was also a leader in the homeopathic movement
j. Commonly called resistive exercises
k. Cofounders of the neuromuscular technique
l. Developed the therapeutic touch–energetic approach
2. How would you describe your professional touch m. Range of motion and stretching performed by a
intention? therapist
n. A physician from Battle Creek, Michigan, who used
massage and hydrotherapy
o. Attempts mechanical changes in soft tissue
p. Introduced Swedish movements in the United States
Matching
 Ancillaries that are
more than just extra
• EXPANDED Web-based content on
the EVOLVE site, including 3 hours of
NOTE TO STUDENTS
case studies, demonstrations, As the author, my intent is to make reading this textbook an enjoyable
animated footage, and more! learning experience; I hope my purpose is reflected in the conversa­
• Licensing review questions. tional tone in which I have written the text. My personal conviction
• NEW QUICK CONTENT REVIEW IN is that Mosby’s Fundamentals of Therapeutic Massage effectively pre­
QUESTION FORM, which is a student sents the information and reflects both the heart and the art of thera­
Evolve resource that reinforces key peutic massage. After all, no one cares how much you know until they
concepts in the chapter and allows know how much you care.
learners to quiz themselves as a Sandy Fritz
review and for learning strategies.
• TEACH lesson plan manual for
instructors, which is available on
Evolve at http://evolve.elsevier.com/
fritz/fundamentals/.

xvii
Acknowledgments
My thanks to the all of the professionals who have influenced the content and clarity over mul-
tiple editions of this text to ensure accurate presentation of information.
There are several people who deserve special recognition for their efforts in the publication
of this edition:
Shelley Bertrand, for the incredible photos and for her energy and enthusiasm during the
photo shoot.
Luke Fritz, BS, Board Certified NCBTMB reviewer
My daughter, Laura, and son, Luke, as reviewers, models, and proofreaders, who understand
the commitment necessary to write high-quality textbooks.
And a special thank you to:
All of the individuals on my support team at Elsevier—especially Shelly Stringer, Brandi
Graham, Rich Barber, Maggie Reid, Jeff Ryals, Maria Broeker, and Kate Odem.
The clients I have had for more than three decades, the athletes I work with for a day or
throughout their careers—for constantly challenging me to figure out what to do with all their
assorted bumps, bruises, sprains, strains, breaks, performance stresses, and personalities. And to
all the students I have worked with, for keeping me honest and humble.
It truly has been a team effort.

xviii
 Contents

People-First Terminology, 149

UNIT I Medical Terminology, 153
PROFESSIONAL PRACTICE Body Structure and Bones, Joints, and Muscles, 157
Body Systems: Nervous, Cardiovascular, Lymphatic, and
Immune Systems, 164
1 Therapeutic Massage as a Profession, 2 Body Systems: Respiratory, Digestive, Endocrine, and
Professional Touch, 4 Integumentary Systems, 169
Professional Classifications of Touch, 8 Documentation, 172
Historical Perspectives, 13
Recent Events and Current Professional Trends, 22
Leadership, 25 U N IT I I
FOUNDATIONS FOR MASSAGE BENEFIT
2 Ethics, Professionalism, and Legal Issues, 30
Professionalism and Therapeutic Massage, 32
The Definition of Therapeutic Massage, 39 5 Research Literacy and Evidence-Informed
Scope of Practice, 43 Practice, 188
Evidence-Based/Evidence-Informed Practice, 51 Massage as Art and Science, 189
Ethics and Standards of Practice, 52 Research Literacy, 192
Informed Consent, 54 Current Research Overview, 194
Confidentiality, 58 The Research Process, 202
Health Insurance Portability and Accountability Act of Why Massage Is Effective: Translating Evidence into
1996 (HIPAA), 59 Practical Application, 209
Professional Boundaries, 60 Translating Evidence into Practical Application:
The Therapeutic Relationship, 62 Nervous/Neuroendocrine System, 210
Ethical Decision Making, 71 Translating Evidence into Practical Application:
Communication Skills, 73 Autonomic Nervous System, 213
Credentials and Licensing, 81 Translating Evidence into Practical Application: Somatic
Dealing with Suspected Unethical or Illegal Behavior, 84 Nervous System, 216
Translating Evidence into Practical Application:
3 Business Considerations for a Career in Circulation, 221
Therapeutic Massage, 91 Translating Evidence into Practical Application:
Inspiration, Intention, Intuition, 92 Connective Tissue, 225
Motivation, 93
The Résumé and Cover Letter, 97 6 Indications and Contraindications for Therapeutic
The Interview, 98 Massage, 237
Self-Employment or Employment by Others, 100 Indications for Massage, 237
Client Retention, 104 Approaches to Care, 238
Generating Income, 108 Pathology, 243
The Business/Career Plan, 113 Common Pathologic Conditions and Indications for
The Business Structure, 117 Massage, 247
The Target Market, 120 Contraindications to Massage Therapy, 258
Management, 122
Hallmarks of a Successful Employee, 128 7 Hygiene, Sanitation, and Safety, 270
Personal Health, Hygiene, and Appearance, 271
4 Professional and Medical Terminology for Sanitation, 273
Communication and Documentation, 135 Preventing the Transmission of HIV Infection,
Massage Therapy Terminology, 136 Hepatitis, Tuberculosis, and Other Contagious
Quality of Life Terminology, 144 Conditions, 284
Cultural Competency and Humility, 149 Premise and Fire Safety, 286
xix
xx Contents
UNIT III
THE MASSAGE PROCESS
8 Body Mechanics, 296
Research: Efficacy of Body Mechanics in Massage
Therapists, 297
Ergonomics and Biomechanics, 300
Gender Differences, 318
Self-Care and the Effects of Improper Body
Mechanics, 321
9 Preparation for Massage: Equipment, Professional
Environment, Positioning, and Draping, 332
Equipment, 332
Massage Environment, 338
Determining a New Client’s Expectations, 342
Feedback, 344
Premassage and Postmassage Procedures, 346
Positioning and Draping the Client, 348
10 Massage Manipulations and Techniques, 356
Quality of Touch, 357
Types of Mechanical Force and Massage
Manipulations, 360
Massage Techniques Using Joint Movement, 382
Muscle Energy Techniques, 392
Sequence and Transitioning: the Basic Full-Body
Massage, 402
11 Assessment Procedures for Developing a
Care/Treatment Plan, 435
Assessment, 437
Physical Assessment: Objective Aspect of
Assessment, 442
Posture Assessment: Standing Position, 447
Gait Assessment, 454
Assessment of Joint Range of Motion, 457
Basic Orthopedic Tests, 459
Assessment by Palpation, 462
Assessment Procedures for Muscle Testing, 474
Putting It All Together: Functional Biomechanical
Assessment, 496
Clinical Reasoning and Problem Solving, 500
UNIT IV
BEYOND THE BASICS
12 Complementary Bodywork Systems, 510
Complementary Bodywork Systems, 512
Hydrotherapy, 514
Hot and Cold Stones, 526
Aromatherapy, 529
Implement-Assisted Massage—Safety First, 534
Lymph, Blood, and Circulation Enhancement, 536
Connective Tissue Approaches, 547
Trigger Point Treatment Approaches, 556
Asian Bodywork Methods, 561
Ayurveda, 570
Biofields and Polarity Therapy, 572
Reflexology, 579
13 Massage Career Tracks and Practice Settings, 588
Therapeutic Massage in the Wellness/Spa/Franchise
Environment, 589
Therapeutic Massage in the Health Care
Environment, 601
Therapeutic Massage in the Sports and Fitness
Environment, 614
14 Adaptive Massage, 620
Animal Massage, 621
Athletes, 628
Breast Massage, 636
Pregnancy, 637
Pediatrics, 641
Geriatrics, 645
Acute Care, 648
Chronic Illness, 649
Oncology Care, 651
Hospital, Long-Term Care, and Hospice Patients, 654
Individuals with a Physical Impairment, 658
Individuals with a Psychological Diagnosis, 661
15 Wellness Education, 669
Challenges to Wellness, 670
The Body: Nutrition, 672
The Body: Physical Fitness, 675
The Body: Relaxation, 679
The Mind, 684
The Spirit, 687
16 Case Studies, 690
Case 1. Generalized Stress and Anxiety with Breathing
Pattern Disorder Symptoms, 692
Case 2. Muscle Tension Headache, 696
Case 3. Generalized Pain Syndrome: Subclinical
Fibromyalgia, 698
Case 4. Neck and Shoulder Pain with Limited Range of
Motion, 701
Case 5. Generalized Low Back Pain with Limited Range
of Motion, 704
Case 6. Athletic Delayed-Onset Muscle Soreness, 707
Case 7. Third Trimester Pregnancy, 709
Case 8. Premenstrual Syndrome, 711
Case 9. Repetitive Strain/Overuse Injury: Bursitis, 712
 Contents xxi

Case 10. Joint Sprain with Underlying Hypermobility AP P EN DIX A

and Lax Ligament Syndrome, 715 Indications and Contraindications to Massage, 742
Case 11. Osteoarthritis and Arthrosis, 717
Case 12. Nerve Impingement Syndrome, 720 AP P EN DIX B
Case 13. General Relaxation, 722 Skin Pathology: Common Skin Disorders, 756
Case 14. Sleep Disturbance, 723
Case 15. Circulation Impairment, 726 AP P EN DIX C
Case 16. Fatigue Caused by Cancer Treatment, 728 Basic Pharmacology for the Massage Therapist, 758
Case 17. Breathing Disorder: Asthma, 730
Case 18. Seasonal Affective Disorder, 733 GLOSSARY, 765
Case 19. Sports Performance Enhancement, 736
Case 20. Scar Tissue Management, 738 I N DEX, 776
This page intentionally left blank
 UNIT I
Professional Practice
1 Therapeutic Massage as a Profession, 2
2 Ethics, Professionalism, and Legal Issues, 30
3 Business Considerations for a Career in Therapeutic Massage, 91
4 Professional and Medical Terminology for Communication and
Documentation, 135

To be a successful massage therapist, you will need two classifications of skills: soft skills and hard
skills. Soft skills, such as communication, etiquette, friendliness, teamwork, problem solving,
interpersonal skills, and leadership, are essential to success. Hard skills are specific teachable
abilities that can be measured. The massage skills, as well as some business and documentation
skills, are considered hard skills. Soft skills are related to social and emotional intelligence. Daniel
Goleman, a psychologist, wrote a book in 1995 titled Emotional Intelligence, and he and others
have continued to investigate and describe the importance of human interaction. Soft skills relate
to social neuroscience—the study of what happens while people interact. We now know that
intelligence is multifaceted, and the soft skills in this unit are just as important for career success
as the massage (hard) skills you will learn in Units 3 and 4. The information in the first four
chapters of this textbook combine to address the spectrum of soft skills including the mindset,
behavior, and interpersonal skills needed to function as a massage therapist in a professional
setting. In addition hard skills needed for business and documentation skills are presented. Unit
2: Foundations for Massage Benefit will support Unit 1 and bridge to Unit 3: The Massage Process
and Unit 4: Beyond the Basics. So let’s begin Unit 1, Professional Practice, starting with Chapter
1: Therapeutic Massage as a Profession.

LEARN MORE ON THE WEB

This feature will appear at the end of each chapter and leads you to valuable information
provided by the various departments of the U.S. government (and sometimes those of other
countries). Unless specifically noted, the content in the LEARN MORE features is in the public
domain and free for you to use. The links and additional information are found on the Evolve
website. For example, soft skills such as communication, attitude and teamwork are extremely
important in a service profession such as massage. The U.S. Department of Labor has many
resources to expand your knowledge on these topics. Use search term soft skills.
On the Evolve site, you will find the links and topics. For example: Soft Skills: U.S.
Department of Labor (http://www.dol.gov/odep/topics/youth/softskills/)
Soft Skills to Pay the Bills—Mastering Soft Skills for Workplace Success
Soft Skill #1: Communication
Soft Skill #2: Enthusiasm and Attitude
Soft Skill #3: Teamwork
Soft Skill #4: Networking
Soft Skill #5: Problem Solving and Critical Thinking
Soft Skill #6: Professionalism

1
Another random document with
no related content on Scribd:
rafforzassero in vece il carattere e sollecitassero l’ingegno alle
imprese memorabili?»
Dai libri di poesia, ch’egli continuamente leggeva, saliva al suo
cervello, come un profumo inebriante, il culto fanatico, la
glorificazione, l’apoteosi della grande passione, che l’Arte ha
generato e cui l’Arte filialmente venera. Per quei poeti, gente nobile
e illustre, l’Amore era tutto: era l’armonia dell’universo, la fiaccola del
genio, era la gioja, era l’ideale, era la divinità. Senza l’Amore, il
mondo non aveva più sole; senza l’Amore, la pace, la gloria, le
ricchezze, la stessa fede non eran se non parole vuote di senso,
ornamenti derisorii gittati sopra un corpo piagato e difforme. —
Perchè vivere se non per amare? — si chiedevan quei poeti,
volgendo in torno gli sguardi assetati di felicità. E il cuore del giovine
ripeteva profondamente, come un’eco fedele: «Perchè, perchè
vivere se non per amare?»
In quegli ultimi giorni, ispirato da quelle voci fascinevoli, sospinto dal
pensiero che l’altro stava per ritornare, Aurelio divenne ardito,
risoluto, intraprendente, non trascurando mezzo alcuno a fin di
raggiungere il suo scopo nel termine prefisso. Ormai nessuna
incertezza rimaneva in lui su quanto avrebbe dovuto fare per
costringere Flavia a una risposta sincera e decisiva: occorreva
parlarle a cuore aperto, dichiararle senza ambagi il suo sentimento,
chiederle con lealtà se lo potesse ella, ora o in un giorno non
lontano, contraccambiare; bisognava abbandonare i piani lenti e
astuti per appigliarsi alle risoluzioni rapide ed energiche. Ma come
trovarla sola? Con qual pretesto domandarle un colloquio in
disparte? Ed era forse possibile ottenere un risultato da una
conversazione a bassa voce in cospetto delle altre donne?
La migliore occasione per trovarla sola era irremissibilmente
sfumata. Dal giorno, in cui egli s’era spinto fino al sommo della
pineta, Luisa aveva pregato la zia di trasportarle l’esercizio di
pianoforte alla mattina, e non aveva più lasciato Flavia durante
l’intero pomeriggio. Aurelio, risalito là per ben due volte pien di
speranza, aveva dovuto ritornarsene deluso e scorato in palazzo,
dopo aver passato un’ora di supplizio ineffabile accanto alle due
giovinette.
Egli procurò dunque di farsi intendere da lei a sguardi, a reticenze,
ad allusioni velate durante i ritrovi comuni sul rialto; si diede a
corteggiarla nettamente e volgarmente, sedendole con ostentazione
sempre vicino, cercando di trascinarla per gradi ad appartarsi dal
crocchio, a discorrere con lui solo di cose intime, discrete,
confidenziali. Più volte, nella mezz’ombra dei crepuscoli caduchi,
sdrajato al suo fianco su l’erba dello scalere, egli, approfittando d’un
momento opportuno, riuscì a parlarle del mutamento avvenuto in lui
negli ultimi tempi e ad accennarle i suoi nuovi desiderii; anche tentò,
con qualche inchiesta astuta, d’investigare a fondo nel mistero della
sua sensibilità. Ma le presenze estranee esercitavan pur sempre sul
suo spirito una bizzarra influenza: egli, per sottrarsi alla loro
soggezione, doveva dare alle sue frasi sentimentali un tono fatuo e
giocoso; egli doveva discorrere scherzando, a similitudine d’un
balbuziente che, per vincere la difficoltà di parola, bisogna che canti.
Flavia, d’altra parte, pareva che si prestasse amabilmente a quel
giuoco: lo ascoltava con visibile piacere, e gli rispondeva a tratti
ridendo, schermendosi dalle celie con altre celie più leggere.
— Via, signor Aurelio, — gli diceva talvolta, oppressa dalla sua
insistenza: — sarebbe tempo di finirla con questa burla. Io non
posso credere a una sola dalle sue parole. Non posso credere
ch’ella parli da senno; e, le confesso, non mi garba d’esser burlata.
— Ma io parlo da senno, signorina, — egli affermava, cercando
d’atteggiare il viso a una espressione più seria.
— Lei? con le sue idee? con il suo orgoglio? con le sue belle
opinioni su le donne?... Ma mi stima dunque così ingenua e,
diciamolo pure, così sciocca da credere cecamente a tutto quanto mi
si racconta? Ella, caro signore, vuol divertirsi un poco alle mie spalle;
ma io, benchè non sia che un povero essere inferiore, ho però
almeno tanta intelligenza quanta ne occorre per intenderlo.
Altra volta, gli chiedeva anche con voce grave, quasi malinconica:
— Perché mi dice queste cose, signor Aurelio? Se scherza, ha torto
di scherzare. E se parla sul serio, ho torto io d’ascoltarlo.
E il giorno ultimo venne, inaspettato, senza che Aurelio avesse
potuto effettuare anche in minima parte il piano di conquista, che gli
era già sembrato così agevole e d’esito quasi sicuro!
Ritornò il padre Boris, ritornarono gli ospiti, riapparve il pretendente
basso e tarchiato, dalla pelle olivastra e dagli occhiali d’oro. Venne
anche a sera lo Zaldini, più fresco e più giocondo che non mai,
essendo stato chiamato per lettera dall’Imberido in sèguito alle
preghiere insistenti di Luisa.
La comitiva a bastanza numerosa, divisa in tre imbarcazioni, lasciò il
villaggio verso le cinque del pomeriggio per passare la notte a
Baveno ed esser pronta, la mattina dopo per tempo, a intraprender
l’ascensione del monte. In una lancia erano l’ingegnere Boris, il
Siena e le due fanciulle; in un’altra la signora Teresa, sua cognata e
Giorgio Ugenti; e nella terza infine, donna Marta accompagnata da
Camilla, e Aurelio e Luciano ai remi. La vecchia quantunque
indisposta e sofferente, aveva voluto seguire la comitiva almeno fino
a Baveno, dove sarebbe rimasta con la fantesca in aspettazione, per
far ritorno a Cerro insieme con gli altri nella sera successiva.
Una grande tristezza occupò l’anima del giovine durante la lunga
traversata e durante il pranzo interminabile alla tavola rotonda
dell’Hôtel Belle-Vue. Nel silenzio del lago, battuto da un sole
bianchissimo, nella gran sala oblunga, popolata d’Inglesi impassibili
e di Tedeschi ciarlieri, il pensiero di Flavia non lo abbandonò un solo
istante, e la presenza del rivale, sempre accanto a lei, non cessò di
martoriarlo, come un cancro ostinato che gli rodesse il cuore. In
vano lo Zaldini tentò più volte di farlo sorridere con le sue storielle e
il racconto grottesco d’una sua recente avventura d’amore; Aurelio
rimase pertinacemente muto e grave, finchè questi, tediato dalla sua
indifferenza, si risolvette a volgergli le spalle e ad appiccar discorso
con un vecchio signore inglese, suo vicino di mensa. Ora Luciano
chiacchierava allegramente e senza ritegni con il nuovo suo amico,
decantando nel più pretto idioma britannico la bellezza
incomparabile delle misses e l’eccellenza del gin e del whisky come
eccitanti delle più pazze fantasie.
— Io, se per avventura m’ammoglierò, — diceva lo Zaldini a voce
alta, — sarà senza dubbio con una signorina del vostro felice paese,
perchè adoro il biondo dei capelli e delle sterline. E voglio, la sera
delle nozze, rinnovare il celebre aneddoto del campanello elettrico,
che voi probabilmente conoscete, poichè l’eroe ne fu un vostro
compatriota, anonimo ma non per questo meno degno di memoria...
Il vecchio accennava di no col capo, incoraggiandolo a continuare
con un’occhiata piena di curiosità lasciva. E il giovine infatti, senza
farsi pregare, raccontava l’aneddoto salace, piegando il capo verso
di lui, soffiandogli le parole fioche all’orecchio, scoppiando a tratti in
una risata sonora, che trasfigurava per incanto il viso terreo e severo
dell’ascoltatore.
Nulla irritava di più lo spirito ansioso dell’Imberido che il cicaleccio
frivolo e ininterrotto de’ suoi due vicini. A intervalli, tra lo strepito
dell’acciottolìo e delle conversazioni diffuso per la vasta sala,
giungeva a lui, come un avvertimento di sventura, la voce fessa e
nasale dell’avvocato, seduto al fianco di Flavia a quattro posti in
distanza dal suo. Egli, roso dalla gelosia, aguzzava l’udito a quel
suono sgradevole, che pareva per poco dominare ogni altro romore;
a volte, credeva di comprendere qualche frase inconcludente,
un’affermazione, un ringraziamento, il nome dell’amata proferito
dalle labbra odiose; ratteneva profondamente il respiro per afferrare
il senso dell’intero discorso. Ma uno scroscio d’ilarità si levava
d’improvviso presso di lui, e tosto la voce si disperdeva nel clamore,
vinta e soffocata.
Aurelio doveva fare un enorme sforzo di volontà per contenere il suo
dispetto contro l’amico e vincere l’impulso cieco di levarsi in piedi e
allontanarsi da quella sedia di tortura. Almeno gli fosse toccato in
sorte un posto di fronte a Flavia e al rivale! Avrebbe potuto scrutarli,
spiare i loro movimenti, i loro sguardi, le loro espressioni! Avrebbe
potuto leggere su le loro facce il sentimento che li occupava! In vece,
da quel posto, non gli era dato nè di vederli nè d’ascoltarli! Egli,
anche sporgendo il capo in avanti, non riusciva a scorgere se non le
loro mani, così prossime che parevan toccarsi, così mobili nella
comune bisogna, che tal volta egli non sapeva distinguere le une
dalle altre!...
Dopo il pranzo, la comitiva uscì dall’albergo per fare una breve
passeggiata prima di coricarsi, e si diresse a piccoli gruppi verso
Stresa su la gran via provinciale che costeggia il lago fino ad Arona.
Il vespero era chiaro, pallido, còrso come da un brivido voluttuoso. I
vasti boschi di castagni, che avvolgono le falde del Motterone,
piovevano su la strada polverosa una frescura umida, un profumo
penetrante di terra e di vegetazione. Dal lago, a pena increspato
presso le rive, saliva un odor caldo di pesci e d’erbe fracide. L’isola
Superiore, sola su le nebbie delle lontananze, spiccava nitida dalle
acque, con le sue case fitte e inghirlandate, con il bianco campanile
della chiesuola acuminato verso il cielo, come un ideale.
Le donne procedevano insieme; poi venivan gli uomini in due file: il
Boris d’avanti tra l’Ugenti e il Siena; e Aurelio e Luciano in coda.
Luisa, accanto a Flavia, accennava a mezza voce,
malinconicamente, l’aria preferita del Faust; donna Marta, eccitata
dalla novità del luogo e dalla compagnia numerosa, parlava forte,
con animazione quasi febbrile, al braccio della signora Teresa e della
sorella dell’ingegnere.
L’Imberido, che si sentiva più calmo e come rassicurato, domandò
sorridendo all’amico:
— Perchè hai tardato tanto a ritornare a Cerro? Hai dunque sùbito
dimenticato la signorina Luisa e i tuoi entusiasmi sentimentali per
lei?
— Dimenticata? non del tutto. Ma, che vuoi? appena giunto a Milano
fui travolto in quell’avventura eroica, che t’ho narrata e tu non hai
avuto la bontà d’apprezzare. Ho corso due volte serio pericolo di
vita; ho passato intere ore rinchiuso in un armadio, come un vecchio
soprabito; ho visto un marito passarmi d’innanzi col lume in una
mano e un’enorme mazza ferrata nell’altra. Capirai: le commozioni
violente esercitano una certa influenza su la memoria: ed io per il
momento ho scordato la bionda incantatrice e l’innocente idillio
campagnuolo. Però, come vedi, al solo nome di lei apparso in una
tua lettera d’invito, io non ho esitato a lasciar Milano, ed ora sono
qui. Che puoi pretendere di più dalla mia fedeltà?
— E... come hai trovato Luisa al tuo ritorno? — ridomandò Aurelio
con ironia.
— Ah, per questo, mutata, molto mutata! Forse, te lo confesso, mi
son lasciato troppo desiderare. Ma... e tu, tu come te la sei passata
in questi due mesi di convivenza con l’altra, con la bruna, nel
palazzo fatato, tra i boschi maravigliosi? Sarei curioso d’accogliere
oggi le tue confidenze: credo che ne sentirei di carine. L’eremita mi
ha l’aria d’essersi fatto diavolo. M’inganno?
— Assolutamente, — rispose sicuro l’Imberido, fissando gli occhi a
terra. — La signorina Boris è in teneri rapporti con quel signore dagli
occhiali d’oro, che ci precede. Si parla anzi d’un prossimo
matrimonio con lui.
Lo Zaldini parve molto maravigliato dalla notizia.
— Davvero? Ma ella sarebbe fortunatissima, caro mio! — egli
esclamò. — Io conosco il Siena da molti anni. È un giovine
coltissimo e simpaticissimo! Uno degli avvocati più apprezzati e
meglio retribuiti di Milano! E poi, è molto ricco: figùrati che ha
ereditato, or non è un anno, cinquecento mila lire da uno zio di
Ferrara. E sua madre è nata di casa Orbetello, figlia del celebre
banchiere di Roma, arcimilionario. Se è vero quanto mi racconti, la
signorina Boris fa uno dei più splendidi matrimonii che si possano
imaginare.
Aurelio ascoltò, contenendosi a stento, l’elogio del rivale aborrito,
detto senza malizia da una bocca fraterna. Non ebbe un gesto di
protesta; non una contrazione di spasimo, non un tremito delle mani,
non un battito delle palpebre. Ammutolì, si fece smorto in viso,
sentendo penetrare nel cuore a una a una le parole dell’amico, come
trafitture di spillo. Gli parve che tutto crollasse intorno a lui. Gli parve
di udire la sua condanna mortale pronunciata da un giudice
inappellabile. — Che valeva omai resistere? Che valeva lottare? A
che servivan la sua ostinazione e il suo orgoglio? Costui era il
preferito, era il vittorioso, era il più forte. Costui era l’invincibile,
d’avanti al quale bisognava per necessità cedere o soccombere.
Una divina speranza si spegneva, troncata da quelle affermazioni,
irreparabilmente. La luce non era più luce, la vita non era più vita!
Nel ritorno egli non parlò più.
Scendeva la sera e il vento aumentava su la montagna oscurata.
Dalla gola di Mergozzo, già invasa dalle tenebre, venivano a
intervalli i soffii striduli e subitanei, si riversavano scrosciando su le
acque, giungevan senza freni alla terra, e quivi, irritati dall’ostacolo,
imperversavano contro la foresta, che si piegava e si torceva con un
fragor formidabile di ruina. E l’anima del giovine avvizzita e divelta
dal dolore, pareva seguire travolta il cammino della corrente aerea,
anelando alla distruzione, alla dispersione, all’annientamento totale
di sè stessa, tra il folto di quegli alberi conquassati, verso le
lontananze misteriose, dove le raffiche ululando s’inabissavano.
La notte era ancora profonda, quando la comitiva lasciò l’albergo e
s’incamminò al lume fioco delle lanterne su per le falde boscose del
monte. Durante un lungo tratto nessuno parlò per il calle aspro e
angusto, serpeggiante sotto la verzura profonda: procedettero tutti,
uno dietro l’altro, in silenzio, ancora un poco ottusi dal sonno
bruscamente interrotto, intenti con gli sguardi al suolo, che le
sporgenze delle radici e delle rocce rendevano insidioso. A metà
della selva per la prima volta riposarono: le donne più affaticate
sedettero su i macigni o su l’erba, gli uomini rimasero in piedi vicino
a esse, in aspettazione.
L’aria era fresca e ancor buja: il vento, alquanto scemato di forza,
stormiva tra le fronde, spostando i brani di cielo visibili in cui
palpitavano gli astri. Verso l’oriente l’azzurro incominciava a
impallidire.
Si scambiarono poche parole durante la sosta, che fu assai breve: le
signore, assalite dai brividi, si lamentarono del freddo e sollecitarono
la partenza. Ripresero tutti insieme il cammino, nel medesimo ordine
di pocanzi, con la stessa svogliatezza muta, con una maggiore
preoccupazione del terreno. Man mano che salivano, il sentiero si
faceva più ripido e più scabro, l’ànsito dei viandanti, più frequente e
più grave. E il bosco si diradava, e i castagni immiserivano tra la
ghiaja, e il cielo costellato si schiudeva più libero sopra le loro teste.
Si udiva solo, nel silenzio antelucano, il ticchettare monotono dei
passi contro le pietre mobili del calle, si scorgeva omai là, lontano
sotto di loro, il lago, simile a una vasta distesa di pece brunastra,
simile a un immane stagno limaccioso in mezzo alle incerte forme
delle montuosità.
La comitiva, un poco avvivata dall’aria più leggera, giunse al confine
della selva e in vista della vetta, quando l’alba imperlava già
l’orizzonte sopra i colli di Lombardia. Gli ultimi alberi crescevano sul
ciglio d’uno sprone scosceso, al sommo del quale l’erta d’un tratto
s’addolcisce larghe praterie irrigue s’incurvano mollemente,
appoggiate a una tenue concavità e quindi al pendìo terrigno del
monte. Nel chiaror livido dell’ora, quei prati avevano una tinta cupa e
unita, d’una inimitabile morbidezza; e qua e là, di tra l’erbe,
balenavano foscamente le grandi pozze degli abbeveratoi o
spiccavano le macchie nere delle stalle e delle capanne pastorizie.
Un tintinnìo languido di campani e qualche sordo muggito venivan
dall’alto, dove una mandria usciva in quel punto per il pascolo.
Come la viottola si stendeva più larga e più agevole, la comitiva
ruppe per ragunarsi l’ordine primiero di marcia, e le conversazioni
non tardarono ad accendersi. Camminavano tra i prati, quasi su un
piano, disposti in due schiere, stretti gli uni agli altri, rinvigoriti e
imbaldanziti dalla brezza e dalla vision della mèta. L’Ugenti e lo
Zaldini apparivano allegrissimi, e gareggiavano in dir motti e
sciocchezze, che sollevavan l’ilarità delle quattro donne; e il Siena a
volte li secondava, con la sua flemma mordace e quasi maligna. Ma
Aurelio seguiva astratto e taciturno i compagni, volgendo gli occhi
inquieti su la severa maestà del paesaggio.
Era in lui, dal momento in cui aveva lasciato l’albergo, una
perplessità strana e confusa, che era andata a grado a grado
addensandosi fino a opprimerlo come un’angoscia. Aveva passato
una notte insonne, sprofondando gli sguardi nel vortice della sua
infelicità; aveva sentito più volte morire le sue speranze e risuscitare
per novamente morire; aveva singhiozzato come pazzo nelle
tenebre, immemore dell’amico che dormiva tranquillamente accanto
a lui. Ma poi, quasi per un prodigio, appena su la via, ogni triste
ricordo s’era spento, ogni doloroso residuo erasi dileguato nel suo
pensiero; ed egli era caduto in una specie di torbida incoscienza
animale, rotta da fuggevoli proponimenti e da incerte fantasie. Ora
egli seguiva i compagni astratto e taciturno, occupato tutto da un
pensiero ignoto, da un’ignota volontà, da un’intenzione che rimaneva
occulta nei recessi impenetrabili dell’essere.
Il pianoro fu ben presto attraversato. Il calle per giungere alla cima si
drizzò più arduo che non mai, lungo il dorso eretto, sdrucciolevole
per le infiltrazioni delle acque, che costituisce la mole centrale della
montagna. La comitiva dovette sbandarsi di nuovo, e ciascuno
separatamente intraprese l’ultima ascensione, chi seguendo il
cammino più comodo tra i margini del sentiere, chi cercando il
tramite più diretto su le zolle madide del prato.
Un superbo spettacolo si svolse frattanto, da ogni parte, intorno a
loro. La luce aumentò con rapidità, come regolata da una mano
impaziente: l’erbe splendettero, si copersero d’innumerevoli fiori; le
pozze degli abbeveratoi si rischiararono; le stalle e le capanne
pastorizie spiccarono con le loro forme pittoresche tra il verde
uniforme delle praterie. Di qua e di là, su la frescura dei pascoli,
apparvero distintamente le mandrie e i greggi, che si udivan prima
tintinnare, muggire e belare nell’ombra. Quando il chiarore si diffuse
più crudo, le catene dei monti, abbraccianti il Verbano, si fecero tutte
palesi nella loro ricca vegetazione fino alle estreme punte
settentrionali, si propagarono come un’immensa successione di
gigantesche onde impietrite rimaste a vestigio d’una qualche
primordiale fluttuazione tellurica. E, in basso, il lago opaco e inerte si
mostrò lucido e bianco nell’alba, simile a un bel fiume di latte, simile
a una favolosa lama d’argento piombata dall’alto e affondatasi per la
sua gravità nelle onde della terra molle.
In fine l’aurora venne a tinger di rosa l’orizzonte lontano. Sul monte
Nudo, sul Sasso del Ferro, su i colli di Mombello, lungo la linea quasi
diritta delle campagne d’Ispra e di Ranco, una zona di luce rancia si
prolungò in guisa d’un nastro serico che orlasse per vaghezza i
capricci del litorale. Quasi sùbito, alcune strisce di vapori si formaron
per incanto nell’aria pura; parvero imbeversi, come spugne, delle
tinte calde dell’aurora; s’accesero, fiammeggiarono preannunziando
l’avvento glorioso del sole. E questo maravigliosamente comparve,
fuor del dosso precipitoso che incombe sopra Laveno, prima come
un punto incandescente e poi come una gran bolla di fuoco espressa
dalle viscere del monte. Le vette s’imporporarono; i raggi discesero a
grado a grado per le chine, cospargendole d’oro; avvolsero in una
nebbia adamantina le falde boscose; s’infransero in ultimo su la
superficie delle acque, provocando nell’urto l’accensione subitanea
d’infinite scintille.
Il nuovo giorno era fatto. Le campane dei villaggi squillarono a festa,
in segno di saluto.
La comitiva fu sbandata e dispersa dalle difficoltà sempre crescenti
dell’ascesa. I più giovini e i più validi, procedendo lunghesso i prati,
s’allontanarono dagli altri che rimasero in basso, trattenuti
dall’affanno e dal calore. L’Ugenti e lo Zaldini, offrendo le mani a
Luisa, trascinandola a forza su per l’erta, scomparvero primi alla
vista dei compagni in una valluccia angusta, avvivata da un ruscello
garrulo e schiumeggiante. Il Siena più cortese restò sul sentiere
tortuoso con la signora Boris, l’ingegnere e sua sorella, per
soccorrerli nei passi disagevoli. Aurelio e Flavia si trovarono d’un
tratto soli e liberi, come smarriti nel monte deserto, su una piccola
prominenza erbosa a metà della china.
Quando il giovine se n’avvide, volgendo gli occhi in torno, ebbe un
sussulto improvviso e violento in tutto l’essere. — Flavia era là,
d’avanti a lui, come in quel giorno lontano sul minuscolo prato al
sommo della pineta! Ella saliva pianamente per quella distesa
inclinata, tra l’intonsa verzura, lasciando dietro di sè un mobile solco
di fili prosternati. Portava ancora, come in quel giorno, l’abito grigio,
attillato, senza guarnizioni, che una cintura d’un color di lilla pallido
avvinceva strettamente sopra i fianchi sobrii e a pena arcuati. E
recava in testa il cappellaccio di paglia dalle tese larghe e convesse,
su cui risaltavan due tulipani sanguigni in un ciuffo di foglie e di
spiche.
Oh, le memorie, le memorie! — Aurelio si volse, fissò gli sguardi
laggiù verso il lago, all’opposta riviera dove biancheggiava il villaggio
solitario. Era là, sotto di lui, remotissima, la pineta del palazzo, simile
a un ammasso di cose oscure, indefinibili; era là il luogo nascosto e
favorevole, dov’ella aveva per la prima volta incantato la natura e la
sua anima. Ancora ella lo incantava; ancora e più, ella con la sua
grazia annobiliva e irraggiava le apparenze per mezzo a cui
passava. Eretta su lo sfondo verde e fiorito, come in quel giorno
lontano, ella era simile a un’imagine immortale e immutabile. Anche
una volta il giovine, contemplandola, non vide in lei la fanciulla
ch’egli ben conosceva: vide l’arbitra del suo destino mortale, la
custode della sua felicità, l’incarnazione portentosa del suo più
schietto Sogno di giovinezza; vide l’Unica che avrebbe potuto far di
lui un essere giojoso.
Con un impeto subitaneo, come spinto a tergo da una forza
esteriore, accelerò il passo sul pendìo; e, giunto presso colei che lo
precedeva, disse:
— Flavia, m’ascolti. È la prima volta, dopo molti giorni, che ci
troviamo soli. Io ho passato due settimane di tortura ineffabile,
cercando un mezzo per poterle liberamente parlare..... Oggi
finalmente il caso mi ha favorito.... Ho bisogno di farle una
confessione assai grave e di chiederle un consiglio.
— A me? — ella domandò con un accento ambiguo, d’incredulità e
d’ironia, volgendo a pena il viso verso di lui.
— A lei, Flavia, a nessun altri che a lei.
Poi, dopo una pausa in cui parve ch’egli ascoltasse i palpiti
accelerati del suo cuore, soggiunse:
— Ella mi troverà molto mutato; si stupirà del mio cambiamento
radicale da un mese a questa parte. Io non ne ho colpa alcuna; ho
fatto il possibile, signorina, per soffocare i nuovi desiderii e le nuove
commozioni del mio spirito, per esser forte, per riprendermi e per
dominarmi. Tutto fu inutile. Dirò meglio: ogni sforzo della mia volontà
ribelle non riuscì che ad accrescere i miei turbamenti e le mie
angosce. Io sento oggi che una sola via di salvezza mi rimane:
quella di rivolgermi con tutta franchezza a lei, e di rimettere
fiduciosamente nelle sue mani il destino della mia vita.
— Mio Dio! — esclamò la fanciulla, tentando di sorridere. — È una
responsabilità troppo grave ch’ella mi vuole addossare! Io non credo
d’esser da tanto, signor Aurelio.
Il viso del giovine si coprì di pallore; le sue mani tremarono; i suoi
occhi si volsero inquieti in torno, come se un passo estraneo fosse
risonato d’improvviso dietro di lui.
— Per carità, Flavia, non rida, non scherzi! — egli riprese a dire,
rassicurato dalla solitudine; — ella deve comprendere ch’io parlo ora
con tutta l’anima mia; ella da molto tempo deve aver compreso ch’io
la cerco, ch’io la seguo, ch’io non perdo un’occasione di potermi
avvicinare a lei. Ricorda, Flavia, quel giorno che son salito lassù,
sapendo di trovarla sola, e l’ho interrogata? Ricorda il mio sgomento,
la confusione delle mie parole? Ricorda bene la mia ultima
domanda? Già fin d’allora avrei voluto confidarmi a lei interamente....
Era salito per questo, ella deve averlo compreso... E m’ha dato una
risposta così fredda, così crudele!
Ella, che sempre camminava, sorrise.
— Crudele, ma meritata, — mormorò con un fil di voce, senza levar
gli sguardi dal prato.
— No, meritata, no. Forse, prima; ma poi, poi.... e in quel momento!..
Ebbene, Flavia, ella non sa, non può sapere quanto io ne soffersi.
Ella non sa ch’io ho passato giorni e notti intere, meditando quella
risposta, analizzandola, rivolgendola dentro di me, cercando sotto le
parole i sentimenti che potevano averla dettata.
— E perchè? — ella domandò, interrompendo, con un tono forte di
voce e un atto superbo della testa, che diedero al semplice motto
una significazione profonda.
Egli anche si eresse; egli anche per poco la fissò, sicuramente. Ma
lo sguardo di lei dal basso in alto, uno sguardo armato, turbinoso,
pieno di mistero, lo vinse, obbligandolo ben tosto a distoglier di
nuovo gli occhi dal suo viso. Egli rispose dunque, umilmente, a capo
chino:
— Perchè io l’amo, signorina Flavia.
La fanciulla non si scosse alla grande confessione. Si fermò, in
aspetto indifferente, e mormorò dopo una pausa, abbassando le
palpebre:
— Fermiamoci qui. Aspettiamo gli altri.
— Oh, Flavia! Flavia! — proruppe egli con impeto, irritato da quella
freddezza, esaltato dalla sua audacia, deciso a combattere fino
all’estremo. — Ella non mi risponde? Non ha nulla da dirmi, almeno
per cuore, per pietà? Ella mi respinge dunque così....?!
— No, io non la respingo, — disse Flavia tranquillamente, rimanendo
ritta di fronte a lui. — Non è ch’io la respinga. M’aveva chiesto un
consiglio, e volevo pensare coscienziosamente prima di risponderle,
appunto perchè le sue parole m’hanno colpita e il suo sentimento
non mi può che insuperbire. Essere prescelta da lei, nobile,
intelligente, coltissimo: è certo l’ideale sognato da una donna. Ma io
ho sofferto, signor Aurelio; le tristi vicende della vita m’hanno resa
cauta e diffidente.... Io so, io sento che, secondando l’impulso
momentaneo, preparerei la mia, la nostra sventura avvenire... E
questo non voglio.
— Oh, Flavia....
— Ricordo bene le sue parole, — ella continuò, senz’interrompersi,
con un accento vibrato e sicuro, sempre ritta, sempre immobile di
fronte a lui. — «L’uomo deve rimaner solo, libero, senza impegni,
senza legami, se vuol riuscire nel suo intento, se vuol vincere e
dominare.... L’amore è un’umiliazione... La donna è una ruina, un
essere inferiore che affascina e che distrugge!...» Ella vede, Aurelio,
io le ricordo tutte; e le ricordo perchè le ho a lungo considerate e
meditate. Ho creduto allora a lei, come credo adesso; ma devo alle
prime parole prestare una fede maggiore, perchè quelle eran dette
pacatamente, risolutamente, senza influenza di commozione o di
sentimentalità. Ora, pensi, pensi, Aurelio: come potrei, con la
memoria lucidissima delle sue massime sconfortanti, abbandonarmi,
spensierata e fiduciosa, all’illusione presente, al fascino ingannevole
d’un sentimento, che in lei non può durare?...
— Oh, Flavia, ella dubita di me? — egli chiese, con la voce strozzata
dall’affanno.
— Dio me ne guardi! Ma anche lei oggi si illude; anche lei s’inganna,
in preda a un’esaltazione passaggera, che basterà la più piccola
contrarietà a calmare e a disperdere.... Se io poi le intralciassi il
cammino? Se io potessi un giorno esserle d’ingombro? Se in
avvenire le dovessi costare il sacrificio de’ suoi ideali e delle sue
giuste ambizioni? Ella avrebbe pure il diritto di rimproverarmi questo
momento di debolezza e di malintesa condiscendenza; ed io avrei
segnata per sempre la mia condanna!
— Le mie ambizioni! — egli esclamò, con doloroso sarcasmo. — I
miei ideali! Io non rammento più neppure d’averli sognati!...
— E questo è appunto ciò che più mi sgomenta. Perché un giorno
ella potrà dire con uguale sincerità: «Il mio amore! Io non ricordo più
neppure d’averlo supposto!» E in quel giorno, gli ideali e le ambizioni
si saranno di nuovo impadroniti di tutta la sua anima, come e forse
più che in passato!... Ah, no, no, rifletta bene, signor Aurelio: è
impossibile, impossibile! A lei è riserbato un avvenire di gloria, ben
diverso dal mio. Ella deve restar solo. Alle sue idee predilette, alle
grandi battaglie della vita, ella deve consacrare tutto quello che v’ha
di alto, di buono, di nobile nel suo intelletto e nel suo cuore.
Solamente così potrà vedere giorni felici; poichè il sogno, che ella ha
accarezzato dai primi anni di sua giovinezza, è ben di quelli che si
realizzano o rendono intollerabile qualunque altra realità.
Ella parlava con una tale sicurezza e una tal limpidità, che le sue
affermazioni assumevano su l’animo dell’ascoltatore un’irresistibile
virtù persuasiva. Egli non osava più interromperla; egli la guardava
con un’indicibile angoscia, sentendo a poco a poco passare
nell’anima sua le idee ch’ella gli veniva esponendo e impossessarsi
contro ogni volontà della sua ragione. E vedeva l’ostacolo crescere
tra loro, salire a mano a mano come una nebbia densa, dividerli per
sempre e respingerli indietro, sempre più indietro, verso due plaghe
remote, inaccessibili l’una per l’altra.
— Pensi poi al mio passato, al mio tristissimo passato, signor
Aurelio! Esso pesa sopra di noi non meno grave del suo lieto
avvenire. Pensi alla delusione, ch’io ho sofferta e m’ha distrutto ogni
ingenuità del cuore, ogni fede, ogni entusiasmo! Che cosa potrei
darle io oggi, in cambio del suo affetto? Un povero fiore, sì, ancora,
ma senza profumo e che la bufera ha già fatto baciar la terra!.. Ella
vede dunque: è meglio, è necessario per entrambi che questa follìa
non continui. Lasciamoci da buoni amici, che si conoscono e si
stimano. E proseguiamo senza rimpianti le nostre due vie, che son
diverse e non possono confondersi. Più tardi, creda, ella penserà a
me con riconoscenza; più tardi mi saprà grado d’essere stata forte e
riflessiva in un momento in cui ella non lo era.
Flavia s’arrestò, calma, pensierosa, un poco triste, e lo fissò negli
occhi intensamente.
— Ella, in cuor suo, già m’approva, non è vero? — chiese, con un
pallido sorriso. — Addio, dunque. E... grazie!
Disse anche, dopo un silenzio:
— Si ricordi di me come d’un’amica sincera, devota, immutabile. Io
non dimenticherò quest’ora della mia vita mai, mai...
E gli stese con un atto franco la mano.
Aurelio, passivo e attonito, la prese nella sua, la strinse con forza.
Si udivan da lontano le risa della bionda echeggiare contro il monte
solitario; si udivan di qua e di là tintinnare i campani delle mandrie e
dei greggi su i pascoli.
Il Sogno pareva disperdersi, e il risveglio era assai desolato. Egli era
solo, senza più una speranza, senza più un’illusione. Egli sentiva
nell’anima la necessità fatale d’esser solo, «per riuscire nel suo
intento, per vincere e dominare.» Qualcuno aveva affermata questa
necessità; ed egli se n’era persuaso. Su, su, sempre più in alto, egli
sarebbe dovuto andare, continuamente andare, portando la croce
della sua sapienza, anelando affaticato alla sommità del suo
Golgota, dove avrebbe trovato ad aspettarlo la Morte. Quale forza
terrena sarebbe riuscita a opporsi a una disposizione superna? «Chi,
chi può dunque mutare il destino?»
Così era e così doveva essere. Le gioje dei mortali non eran per lui,
non eran per quelli che son destinati a sacrificarsi a un Ideale, a
versare il loro sangue più puro per fecondar la terra o per imbevere
le sabbie. Su, su, sempre più in alto, egli avrebbe dovuto andare,
continuamente andare, chiudendo gli occhi agli spettacoli giocondi
della vita, per non morire lungo il cammino d’invidia e di desiderio!
Ma non gli era dunque riserbato un conforto, un unico conforto nella
sua gloriosa sventura? Egli cercò avidamente nel suo cuore se un
conforto esisteva. E l’imagine sparuta della nonna gli sorrise benigna
di tra le tenebre, come la prima e l’ultima dolcezza del suo infinito
abbandono.
 X.
Tra l’Amore e la Morte.

La sera del dì successivo l’ingegnere e gli ospiti partirono. Anche

Luisa, richiamata dal padre, dovette lasciare la villa e far ritorno a
Milano in compagnia della sorella Boris. Su la spiaggia donna Marta
e il nipote discesero a salutarli.
Quando le due barche piene, dove avevan preso posto anche Flavia
e sua madre, scomparvero alla vista, la vecchia, ch’era stata prodiga
d’effusioni per tutti e aveva versato anche qualche lacrima
abbracciando la bionda che pure piangeva, ebbe d’improvviso un
colpo di tosse secca, violenta.
— Vedi? Vedi? — le disse Aurelio, impensierito, prendendola sotto il
braccio per ricondurla in palazzo. — Tu oggi dovevi fermarti a letto.
Dopo l’imprudenza di jeri, tu non saresti dovuta alzarti. Prendere
tutta quell’acqua! Arrivare a casa inzuppata come se avessi fatto un
bagno nel lago! E tutto questo, per la tua ostinazione, per non
volermi ascoltare mai, mai!... Non si poteva forse restare un’altra
notte a Baveno? Non si poteva, poiché il tempo minacciava,
rimandare il ritorno a questa mattina? Ma tu, no, tu, come sempre,
hai voluto agire di tua testa; tu hai voluto tentare la traversata,
soltanto perché io ti pregava di non farlo! E, lo sai, io te ne pregava
soltanto per la tua salute.... Ora, vedi? Vedi? Hai la tosse. Ora ti
ammalerai...
— Crepi l’astrologo! — esclamò donna Marta, ridendo.
— Non scherzare, mamma, — proseguì serio e accalorato il giovine:
— quella tosse non mi piace, e bisogna che tu la curi prima che
sopravvenga una qualche complicazione. Alla tua età i mali più
leggeri son sempre pericolosi. Domani in tanto rimarrai a letto. Io
esigo che domani tu rimanga a letto.
— Domani farò quel che mi piacerà.
— No, domani invece farai quel che a me piace, e sarà forse la
prima volta che un caso tanto straordinario accade nella nostra vita.
Donna Marta, ancora commossa dalla scena dei saluti, non era in
vena di discutere e di litigare; e concluse con un sorriso di
compatimento per il nipote:
— Ebbene, domani ne riparleremo.
La mattina dopo; quando Aurelio si presentò nella camera dell’avola,
la ritrovò mezzo vestita d’avanti alla specchiera, in atto di pettinarsi.
Egli ebbe un moto subitaneo d’irritazione che a stento potè
contenere. Le domandò guardandola negli occhi:
— Come? Ti alzi?
Ella rispose:
— Sì, mi alzo.
Ma era più pallida del giorno prima. Era bianca come i suoi capelli,
come la sua camicia. Egli richiese:
— Hai tossito stanotte?
Ella rispose:
— A bastanza. Non ho potuto chiuder occhio fin verso l’alba.
— E ti alzi ugualmente?
— Sì.
— Perchè, mamma? Perchè?
— Perchè lo voglio. Perchè so che, se rimango a letto un giorno, non
mi rialzo più.
— Che sciocchezza!... Del resto, se farai così, quando ti deciderai
infine a rimanervi, sarà troppo tardi e forzatamente il tuo triste
presagio si avvererà.
Egli si avvicinò a lei, la baciò su i capelli, le disse con la voce più
dolce, implorando:
— Sii buona: ritorna a letto, mamma! Ascoltami!
— Non seccarmi! — ella proruppe d’un tratto, irosa. — Non ho voglia
d’esser seccata, stamane! Lo vedi, non mi sento bene! Mi sembra
d’avere il cuore sospeso a un filo! È una crudeltà questa tua di farmi
arrabbiare nello stato in cui sono! Vattene via! Lasciami in pace!
Aurelio comprese ch’era inutile insistere. Uscì dalla camera di donna
Marta, inseguito da un presentimento sinistro. Come fu solo su la
loggia, sentì gli occhi bruciare e inumidirsi; mandò un gran sospiro di
rassegnazione desolata. «Mio Dio! Quanto era pallida! Quanto era
breve la sua respirazione! Se mi morisse?!» egli pensò, trasalendo,
affondando per un attimo paurosamente gli sguardi nell’avvenire.
Durante la colazione, donna Marta si mostrò vivace, ciarliera,
oltremodo allegra, di quella sua allegria nervosa e scomposta che
ricordava un poco l’eccitazione d’un ebro. Domandò con insistenza
al nipote i particolari dell’ascensione, alla quale era stata afflittissima
di non poter prender parte; discorse a lungo dei vicini, profondendosi
in elogi e in attestazioni di simpatia per essi; lo rassicurò anche a più
riprese su la sua salute, affermando che in verità ella non si sentiva
nè meglio nè peggio di prima. Quanto a quel po’ di tosse, càspita,
non c’era proprio di che impensierirsi: ella aveva già ordinato a
Laveno certe polveri miracolose, le quali senza dubbio ne
l’avrebbero liberata in due o tre giorni al più tardi.
— E se non ostante le tue polveri, la tosse continuasse? — chiese
Aurelio, sempre serio, sempre più triste quanto ella si dimostrava più
gaja.
— Non temere: passerà.
— E se non passasse? Due o tre giorni senza cure posson esser
causa di complicazioni anche molto serie, che oggi si riuscirebbe
senza difficoltà a evitare. Pensaci! Vuoi che vada io a Laveno per
chiamare il medico?
— Il medico? Guàrdati bene! Io non voglio saperne di medici! Non
ne ho mai voluto sapere! E poi, ora, non è il caso neppur di parlarne.
Si tratta probabilmente d’un semplice raffreddore; e tu, al solito,
esageri....
Finita la colazione, il giovine uscì dal palazzo, sedette al sole sul
rialto, invaso da una strana malinconia, da un’ansietà inesplicabile.
Erano i residui del colloquio definitivo avuto con Flavia su la
montagna, che gli infondevan quella cupa tristezza? No; gli
avvenimenti di due giorni innanzi gli sembravano irreali e
lontanissimi. Sentiva anzi una discontinuità profonda tra lui e il suo
essere anteriore, tra quel che era stato e quel che era. Le sue
speranze distrutte, il suo amore respinto, la coscienza del suo
avverso destino lo lasciavano freddo e impassibile, com’esse non
riguardassero più la sua persona, ma bensì un’altra ch’egli aveva già
amata ed ora a pena ricordava. Che gli importava di Flavia? Che
parte rappresentava ella nella sua vita? Che conforto avrebbe egli
potuto trarre anche dalla speranza d’essere amato da lei? Ohimè,
nell’ora presente, nessun conforto, nessuno! Altre cure, e più gravi,
assai più gravi, occupavano omai tutto il suo spirito: altri dubbii, altri
pensieri, altri sentimenti. Quali? Egli non sapeva bene e non cercava
di sapere. Egli aveva paura di inoltrarsi nel mistero del suo
accasciamento; provava orrore solo a rivolgervi di sfuggita gli occhi
dell’anima; evitava d’investigarsi, per la tema di precisare il
fantasma, d’udire in fondo a sè l’eco d’una tremenda profezia.
Il sole, un sole autunnale senza forza e senza vita, slargava i suoi
raggi pallidi e velati sul prospetto del palazzo. Qua e là nel cielo
alcuni fiocchi bianchicci di vapore intorbidivano l’azzurro,
oscurandosi e addensandosi verso la pianura. Un silenzio di morte
teneva la spiaggia deserta, dove le barche s’allineavano in disordine,
immobili e abbandonate come carcasse respinte dall’onda.