The somewhat indefinite term "deformity," the meaning of which is seldom defined in the same way in two different books, but which is now more generally limited to congenital or acquired faulty positions of the skeleton or organs of locomotion, denotes merely a deviation from the normal form, but since a pathological form in most cases accompanies a pathologically altered function, one can at least say from the standpoint of medical gymnastics and massage that the general aim in the treatment of orthopaedic cases is to restore a faulty skeletal form, with all that pertains to it, to a normal form, as well as the accompanying abnormal function to a normal function. This expresses the whole existence and aim of orthopaedics. The more one succeeds in restoring a deformity to normal form and function, the better is the result. But it is not enough to restore a deformed portion of the skeleton to its normal form; one must try to maintain the normal form, i.e., to avoid recurrence. And it is all the more necessary to point this out, as in orthopaedics, much more than in other special branches of medicine, one has to expect recurrences; most of the deformities which can be corrected have a remarkable tendency to recur, and in no cases is such a false estimate of the result of treatment formed as in these, when, as is too often the case, only the primary result of treatment is studied.

Every faulty position of the skeleton, and the parts of our locomotor and supporting apparatus connected with it, must have a cause, and in their treatment, as in all other treatment, one must try to reach as far back as possible in the chain of causes and aim at its removal. In the study of different kinds of deformity one speedily finds that the fundamental causes cannot be reached by any of the therapeutic means at the command of practical medicine. To give a concrete example by way of illustration, one may here mention club-foot resulting from paralysis. In this, generally following an acute anterior poliomyelitis, the deformity and the faulty position depend on the disturbed equilibrium between the muscles, the result of the partial or total paralysis of certain muscles or muscle groups; this paralysis again depends upon the destruction of certain motor cells in the anterior horn of the spinal cord, for which destruction naturally we can do nothing. Thus, if we succeed in one way or another in restoring the paralytic clubfoot to its most normal form, the cause of the deformity remains. The deformity must recur, since the original cause persists, viz., the lost equilibrium between the muscles. This and similar conditions in most of the groups of deformities can scarcely be emphasised enough, inasmuch as a regrettable over-estimation of the results obtained flourishes in no other department of practical medicine as it does in so-called orthopaedic gymnastics. To have restored a markedly deformed paralytic club-foot to its normal condition naturally at first appears to the ignorant a very brilliant result, and many gymnasts (e.g., de Ron) have won great reputations by such cures. The value of the cure is greatly reduced in the eyes of those who understand clearly and distinctly that inevitable relapse can only be prevented by quite special measures, and often, unfortunately, not even by these.

The three chief indications for all orthopaedic treatment are to try (1) by prophylaxis to prevent or counteract the appearance of deformity, (2) to restore to normal form and function any alteration in form and function which is already present, and (3) to main tain the restored or improved form and function. My aim in the following special sections will be to state shortly to what extent medical gymnastics and massage play a part in the fulfilment of these different indications. If I cannot mention here all the deformities which may be found, I may nevertheless be able, in connection with the treatment of selected deformities, to state the most important points of view, by the application of which the medical gymnast should be able to carry out the treatment of the various deformities which are not mentioned.

Before I go on to discuss the importance of medical gymnastics and massage in the treatment of the most common and typical deformities I will first say a few words on the relationship of manual and mechanical treatment in the field of orthopaedics. While, as already stated, in many other departments of medicine, and especially in the case of diseased conditions in the treatment of which massage plays a considerable part, the purely manual treatment, massage given without apparatus and the so-called Ling medical gymnastics, surpasses the medico-mechanical with machines and other apparatus; this is by no means the casein reference to orthopaedics. Just as the orthopaedist, who has completely at his command all the therapeutic resources of orthopaedics (operation, the technique of plaster and bandaging, gymnastics and massage, etc.), without doubt obtains the best results; the same is true of the medical gymnast's work in orthopaedics. The more numerous and varied means he has at his command the better are his results. And one may say without exaggeration that in the treatment of whole groups of orthopaedic cases the gymnast is somewhat stranded unless he has access to, and understands how to use, mechanical gymnastic apparatus. And it is in orthopaedics that the medico-mechanical gymnastics invented in Sweden (by Zander) have attained their greatest importance in other lands. A very large number of gymnastic apparatus specially constructed for orthopaedic purposes have been invented and are used almost everywhere. Entire systems of medico-mechanical gymnastic apparatus have been constructed in recent times which, in the collections of apparatus of the large medico-mechanical institutes, compete in fundamentals with the original apparatus of Zander, on which they are founded, without, so far as I understand, having yet excelled them for general gymnastic purposes and heart cases. On the other hand, it must be said that quite outside the limits of the Zander system, and even before it in point of time, many mechanical apparatus of great use in orthopaedics had appeared. One must specially mention many correcting and holding apparatus for the treatment of scoliosis, from the simplest, which can be arranged and used without difficulty by the general practitioner, to the most complicated and expensive, which can scarcely be used except in the great orthopaedic institutes. Above all must be mentioned the Krukenberg pendulum apparatus for all kinds of joint mobilisation. Owing to the excellence of the fundamental idea, and the practical way in which it is carried out for its special aim, it has come in an inconceivably short time to be regarded as almost indispensable in orthopaedics, and is used throughout the whole civilised world.

The great and undeniable importance of mechanical apparatus and machines in orthopaedics in no way detracts from the importance of the purely manual treatment. Massage of course plays a great part, and this, except in the varieties of tapotement, can never be quite satisfactorily given by mechanical means; orthopaedic cases, moreover, must often be treated in conditions where mechanical gymnastic resources are not applicable or available. Manual treatment for an orthopaedic case can, moreover, be managed in any place where a good medical gymnast is at work, while mechanical gymnastic treatment can only be obtained in places where orthopaedic establishments or medico-mechanical gymnastic institutes are to be found. Further, the orthopaedist has often to work with small children who have not reached the age of six or ten, before which age medico-mechanical gymnastics cannot be used with any great advantage. Lastly, and above all, one must mention once more that both means used together give better results than one used alone. One sees nowadays in orthopaedic departments abroad, private or public, mechanical and manual gymnastic resources used together in daily closer combination. It is reserved for Sweden, the so-called motherland of both these gymnastic systems, to maintain a curious separation between two gymnastic systems each of itself well justified and together extremely effective, a separation which certainly hampers the development of medical gymnastics.

In the following more special account of the use of medical gymnastics and massage in orthopaedic cases, for reasons already given, only a few types of deformity are described. These have been so chosen that deformities of the spine and trunk as well as of the extremities have been represented, and that in the treatment of the types chosen all the most important points of view are put forward to enable the medical gymnast to arrange his treatment of the many-sided orthopaedic cases in their varied phases so that it shall be as effective and beneficial as possible. The weight of choice has fallen on the purely orthopaedic side, while the large border region which orthopaedics shares with surgery, the treatment of joint inflammations and of bone and joint injuries, has been omitted, since the physical treatment of these conditions has been described in detail in another part of this book.