* "Contribution a l'etude du rheumatisme museulaire," by Dr. (Gustaf Krikortz, These : Paris, 1900.

Traumatic myositis occurs generally in the extremities, the shoulder, or the gluteal region; it is far less difficult to diagnose than the myositis of rheumatic origin, for the history often throws light on the subject, and the results of palpation are much more definite in the former than in the latter. Muscle contusion is often associated with ecchymosis, that is, small patches of haemorrhage in the muscular tissue, which as soon as the blood is coagulated form a circumscribed hard, inelastic swelling. There are also larger or smaller haematomata, which quickly form sharply limited swellings of almost cartilaginous consistency. Such cases are rapidly improved by friction and effleurage. Immediately after muscle contusion it is very important to begin the treatment at once and go on with it until it is completely cured. There are two reasons why this is necessary; one is because otherwise the infiltration of blood becomes organised and soon forms hard fibrous sclerosis in the muscular substance, the other because muscle contusion causes surprisingly rapid and extensive atrophic changes. Especially after the so-called shoulder contusions, it is very usual to find marked changes in outline due to atrophy of the deltoid. All myositis, traumatic and otherwise, is in its first stages easily, quickly, and with certainty cured by massage; less recent cases require months of work, and the treatment of sclerosis and extensive atrophy of muscles is an almost hopeless task.

After excessive or strong muscle contraction, either strain or partial or total rupture occurs in the skeletal muscles, even under normal conditions. These traumatic changes may occur in any part of the muscle, in the tendinous origin of insertion or in the muscle parenchyma. (Violent over-exertion may break off a portion of bone with its muscular attachment.) The commonest ruptures are in quadriceps femoris, the calf muscles, biceps brachii, deltoid, rectus abdominis, and in the muscles of the spine, especially in the lumbar region (traumatic "lumbago ").

The diagnosis is easy, partly from the history, which shows that the patient has felt a sudden smarting pain after or during a strong muscular strain, partly by palpation, which in the case of strain (partial rupture) shows an inelastic tender spot, and in total rupture a swelling more or less filled with blood. After this has healed, the swelling being replaced by new muscular and fibrous tissue, loss of function may persist, and the patient has the sensation of a foreign body being present, and from time to time has spontaneous pains. The sooner the case comes under treatment the more rapid and complete is the effect of effleurage and friction.

Tenosynovitis crepitans, with the usual serous or sero-fibrinous exudation into the sheath, is now mostly treated by massage, which has quite taken the place of tincture of iodine or mercurial ointment. By the use of effleurage and friction the most important symptoms disappear at the end of a few days or a fortnight; if it is thought better to use other means at the same time, it is only necessary to apply cold compresses, leaving them on till they become warm. Bier and others use hot air and hyperaemia.

In clinics frequented by manual workers one unfortunately sees many cases of purulent tenosynovitis. When healing has taken place it is a lengthy and often thankless task to endeavour by means of strong frictions and passive movements to get rid of contractures, which frequently interfere with the patient's work.

Exudation into the tendon sheaths can also be treated by massage, but it is important not to rely too much on exclusive manual treatment, even in non-tubercular cases, especially when multiple. Fluid is often known to resist all treatment by massage. When the condition is obviously of a tubercular nature it is treated by puncture and injection, by hyperaemia, by excision, and by general anti-tubercular treatment.

Chronic inflammation of the fascia is without doubt much commoner than is believed, and often complicates myositis; and, in common with subcutaneous infiltrations of the connective tissue, is often mistaken for myositis or else overlooked. It is seldom on its own account treated by massage, which doubtless may be of considerable use in recent cases in removing the inflammatory products and curing the inflammation of the fascia, thereby preventing shrinking. In the preceding chapter, in speaking of Dupuytren's contracture, I referred to the amount of work required and to the difficulty of obtaining a satisfactory result.

Chronic bursitis, commonest in the prepatellar bursa (housemaid's knee) and in the olecranon bursa, with dilatation of the bursa, thickening of its walls, and increase of the contents (serous, colloid, or often hemorrhagic), is often treated in Sweden with more or less success by friction and effleurage only. Injection of dilute tincture of iodine (1:3) appears to be a better and more certain method of treatment, causing shrinking or obliteration of the sac.

Tubercular bursitis is treated in the same way as tubercular exudation into the tendon sheaths (see above).

Gonorrhaeal bursitis, generally serous (and usually in the bursa Achillis), may, when the acute inflammation has subsided, be treated by massage in conjunction with treatment by Bier's bandage.

In acute purulent bursitis the bursa is opened and healing is promoted by Bier's treatment. Afterwards friction may be used for its absorptive effect.