For the better understanding of the remarks which follow it is necessary to insist upon certain elementary points. If a dislocation is complete in the ordinary acceptation of the term the capsule of the joint must, as a matter of course, be torn, the rent in the capsule being of large or of small extent. The obstacles to the reduction of a dislocation depend comparatively little, as a rule, upon the situation or character of the laceration in the capsule; occasionally only do some of the difficulties met with in attempts at reduction lie with this structure. The real difficulty is for the most part due to muscular contraction - a fact which is amply proved by the manner in which most difficult dislocations will often reduce themselves as soon as the patient is fully anaesthetised. The longer a dislocation remains unreduced the more marked does this contraction of the muscles become, and the more difficult is it to remove the bone from its abnormal site. Supposing that a dislocation remains unreduced for five, or six, or eight weeks in a joint such as, for an example, the shoulder, physiological shortening of the muscles takes place; and in consequence a reduction of the dislocation by ordinary means may become practically impossible. I mention these facts, not because I suppose you are unfamiliar with them, but because I wish to emphasise as strongly as possible the importance of muscular contraction and shortening as obstacles to reduction in the vast majority of the dislocations with which we are ordinarily called upon to deal. For practical purposes the capsule and surrounding bony points may be ignored, since if they form any obstacle to reduction it is generally secondary to the condition of the muscles.

It is further a most important point to bear in mind that under ordinary circumstances after the reduction of a dislocation the retention of the replaced bone in its normal site depends not so much upon the state of the capsule, which in reality has little to do with the matter, as upon the muscles, aided in certain cases by atmospheric pressure. In fact, the question of the healing of the rent in the capsule is of small importance compared with that affecting muscle-waste. The capsule will heal equally well whether the joint be kept fixed in splints or whether it be subjected to passive movement from the first. The muscles about the joint, especially those supplied by the same nerves as supply the articulation, waste rapidly if the joint be kept fixed for ever so short a time, and if the fixation be kept up for long periods this wasting may proceed so far as to be incurable. On the other hand, if massage and passive movement be at once commenced, then wasting can be entirely prevented, in the absence, of course, of actual nervous lesion. If the muscles are allowed to waste to any great extent, as you can easily see for yourselves by watching an ordinary case, the whole joint becomes loose and flabby. There is no such thing as a primary tonic condition of the capsule of the joint: the capsule of the joint is a passive structure, and has no contractile vitality of any sort beyond that which it derives from muscular attachments and expansions. The prolonged fixation of a joint after the reduction of a dislocation allows the muscles to waste, which is tantamount to bringing about the precise conditions which tend to recurrent dislocation if attempts to obtain free movement are made at a later period. The effect of even temporary fixation of a joint in the production of adhesions which have subsequently to be treated, often for long periods, I need hardly, I suppose, impress upon you; although I fancy that if you were to examine a large number of patients who have had dislocations, say of the shoulder-joint, at a long period after the injury, you would be surprised to find that the percentage of cases in which some stiffness still persists from this cause is very considerable.

In the practice of the older school of surgeons prolonged fixation of a joint after dislocation was almost universal, the main object being to allow of a firm and rapid union of the rent in the capsule. So much was thought of the value of the healed capsule in retaining the parts in position that the disadvantages of adhesions and muscle-waste were held to be of no account compared with the vital importance of the completely restored capsule. I strongly recommend you to reverse these conditions by concentrating your attention upon measures for the avoidance of adhesions and muscle-waste. Ignore the torn capsule; the rent will heal soundly in spite of any rational manipulations or movement it may be subjected to in treatment. Ingenious operations which from the nature of things cannot effect material good have been from time to time invented with a view to the cure of recurrent dislocation by shortening the loose capsules, the fact having been overlooked or forgotten that looseness of the capsule is secondary to muscle-waste, which is the real thing to be combated. The only available method by which muscle-waste can be avoided in these cases of dislocation, especially of the shoulder, is massage, commencing immediately after the reduction of the displacement - smooth rubbing only for the first two days, after which passive movement follows the massage. This passive movement may be very free in all directions save that which is towards the muscles which tend to waste. For example, in the case of the shoulder, abduction of the arm from the trunk should not be practised for a week or ten days after the injury, because the strong action of the adductors, unopposed for the time being by the weakened deltoid, tends to displace the head of the humerus inwards. For the same reason in the first week no voluntary movement should be allowed, all movements being passive. Treated on these lines any dislocation of a major joint - e.g. shoulder or hip - may be cured in from two to three weeks without adhesions and with no stiffness remaining. At the end of a week, or at the most ten days, from the date of the injury, free voluntarv movements should follow.

All cases of recurrent dislocation will be found to be associated with marked muscle-waste. The cardinal principle in treatment is in the direction of rectifying the atrophy of the muscles by massage and methodical exercises with or without electricity, and not in the direction of shortening the lax capsule by operation.

The beneficial effect of massage in dislocations is not limited to the treatment after reduction; it is sometimes of great use as an aid to reduction. The following case will serve as an illustration of this point. A highly sensitive and nervous lady, considerably beyond middle age, dislocated her shoulder in a fall which followed a slip on some parquet flooring. There was extreme pain, and the muscular spasm was intense, the least attempt to move the parts eliciting loud cries from the patient. Whilst waiting for the arrival of an anaesthetist, as the muscular spasm was so great, I gently massaged the region of the shoulder, upon which the pain was soon modified and by degrees disappeared. In the course of the rubbing I noticed that the muscles became less hard, and especially I observed that the hollow tension of the deltoid was succeeded by a feeling of almost softness. Seizing the favourable moment I passed my right hand into the axilla and with a sudden outward jerk reduced the dislocation easily (the displacement was sub-glenoid); in fact, had an anaesthetic been administered reduction could not have been more easilv effected. In two other cases of dislocation of the shoulder of a similar kind, one being sub-coracoid, the other sub-glenoid, I have in the same way effected reduction with remarkable ease. Cases like these show further the point I have already insisted upon - viz. the importance of concentrating your mind upon the condition of the muscles in cases of dislocation.

Before leaving the subject of dislocations allow me again to refer to the question of muscle-waste in these cases, because I do not think that in some instances it is sufficiently understood. In the case of the fleshy joints - e.g. the shoulder and hip-muscle-waste, unless the massage treatment is adopted, is too obvious to require comment. Wasting in the same manner occurs uniformly in all dislocations, although it certainly is not recognised by some people. The wasting, for instance, of the quadriceps in certain conditions of the knee is of common knowledge, but I venture to think that the wasting of the muscles controlling the ilio-tibial band is but little realised.1 Again, it would at first sight seem almost impossible that any wasting of muscles should follow upon dislocations of distal joints like those of the phalanges of the fingers which are quite remote from muscular bellies; yet in these it will be found, if examination be made, that there is universally some wasting of the forearm, and, further, that the permanent sense of weakening which is complained of by some of the patients who have suffered from these injuries can only be rectified by voluntary exercises or by thorough massage of the forearm muscles. The bearing of these points upon the scientific treatment of these injuries is too obvious to require explanation; it is, I am sure, of much more importance than is commonly thought. It would, of course, be interesting to describe seriatim and in detail the management of the various dislocations throughout the body by immediate massage and passive movement, but time will not allow of this. I4hope, however, that what I have been able to say will be sufficient to indicate the general principles upon which the treatment should be conducted. Its modification to the requirements of the different joints is merely a matter for the exercise of ordinary intelligence.

1 See Injuries and Diseases of the Knee-joint, by the present writer.