When some little time has passed since the receipt of injury the condition depends entirely on the previous treatment. The points that will now require attention are circulatory troubles, scars, stiffness of joints, adhesions, and the loss of muscular power.

It will save repetition if it is stated at once that the presence or absence of sepsis is all-important as regards prognosis. If sepsis has been present there should be always before us the danger of lighting up a process that has become quiescent. The result of our recent experiences in military surgery has emphasised the fact that no operation of an orthopaedic character should be undertaken for at least six months after the final closing of a septic wound. The masseur should keep this in mind. Many of the limbs we are now called upon to treat, in order better to fit the discharged soldier for civilian employment, are in a parlous state. Months of perseverance can only improve them, and nothing can really cure. But patience can work wonders, while haste will often give rise to the most unpleasant of surprises by causing infection in a limb to flare up in a most disconcerting manner. Apart from the consequences to the patient, it is heart-breaking to see the labour of months thrown away as the result of a fit of impatience on the part of the masseur. But, putting impatience and excess of zeal aside, recovery from the effects of injury that has been complicated by sepsis must be slow and tedious, and the slowness of recovery varies directly with the extent of the sepsis. All attempts injudiciously to expedite recovery are doomed to have the diametrically opposed result.

In the absence of sepsis an excess of zeal will not only cause pain, it may cause synovitis, and will assuredly delay recovery. If long continued, irremediable harm may be inflicted; but this should be confined to those cases where lack of clinical experience and insufficiency of training are the root of the evil. Many reports of various catastrophes have reached the author since the outbreak of war, and it is for this reason that he has made the present attempt to try to supply a substitute, inadequate though it must be, for clinical experience where this is larking. One thing in particular has tended to militate against the success of the massage treatment of the wounded, namely, the attempt to treat more cases in a limited time than can be accomplished with efficiency. Reduction of the time devoted to treatment tends to increase its severity, and herein lie potentialities for much evil. If overworked, the law for the masseur should be - give inadequate treatment and trust to the patient's own efforts more than would usually be deemed desirable, but do not attempt to compress half an hour's treatment into fifteen minutes.

In order to aid the circulation every agent at our disposal must be invoked; but now, as in more recent stages, surface stroking should begin and end the seance. The stroking becomes more and more firm by very slow and gradual stages. The rhythm is maintained throughout. Some form of compression massage follows, commencing if possible above the level of oedema (if present) and gradually working downwards. A constant return to the parts already treated must be made as each new segment of the limb is reached. The use of a mechanical vibrator is often helpful, but should not be continued for more than two or three minutes at a time over one spot. If continued too long it is apt to paralyse the unstriped muscle fibres of the arterioles. It is useless to devote less than twenty minutes to an attempt to render efficient assistance to the circulation of a limb when oedema is present. Half an hour is none too long. The massage need not, however, be consecutive, as it may, with advantage, be interrupted for short spells of active mobilisation. The passive part of the treatment should, of course, be undertaken during the continuance of the massage. (See also Chapter XXXII (The Combination Of Massage And Splintage In Orthopaedic Surgery).)

The treatment of scars is a special art in itself, and some masseurs seem to be endowed by nature with special adaptability for this branch of work.

It is a great misfortune that the beneficent effect of massage in promoting the healing of open wounds has not received a more general recognition. Months of tedious waiting for a wound to heal might often have been reduced by half or one-third, and many an operation for grafting would have been obviated altogether. The reason is not far to seek. One of the most generally recognised features of scar tissue during its organisation is that of contraction. As contraction proceeds the scar becomes avascular. Hence it comes about that, if a wound takes any considerable time to heal (probably anything over six weeks), the resulting scar formed round the periphery tends to contract. This must shut off from the remaining central surface the vascular supply which is required from the periphery in order that healing should proceed rapidly. The tendency can be entirely overcome by massage. The technique is simple, but strict asepsis is essential. In the first place everything we can do should be done to secure the maintenance of the fullest possible blood-supply to the whole part - either by muscular activity, whenever possible, or by massage when this is impossible. Thus, if it is desired to heal a pressure sore over the heel, as full activity as possible of all the thigh and leg muscles should be encouraged. The whole of the skin around the wound or in its vicinity should then be subjected to a thorough dose of dry cupping, following the technique described on p. 370. A very wide area should be treated. In the instance quoted above the whole of the calf and the sole of the foot should receive attention. Frictions with the tips of the fingers follow all round the edges of the wound, the pressure exerted being sufficient slightly to push the edges of the wound towards the centre of the hitherto unhealed area. The frictions should be quite firm and deep. When dealing with old chronic ulcers the tips of a pair of dissecting forceps are wrapped firmly in cotton-wool and the whole of the raw surface is firmly rubbed - it may be even scrubbed - with full strength peroxide of hydrogen. The process is continued until the froth from the peroxide is coloured a pale pink, which, however, soon turns to a dirty brown. The froth is then washed off with normal saline and a moist dressing is applied. It is often useful, while applying the cupping, to keep the cup stationary close to the wound, while the patient is encouraged to move the underlying muscles as freely as possible. If sepsis is still marked the cup may produce a slight pustular acne, and its use must then be discontinued. Occasionally, in the presence of sepsis, the rate of progress is found to be disappointing. In these cases it appears probable that the sepsis is as inimical to healing as the cicatricial contraction in the outlying parts of the scar. Treatment by the ultra-violet rays will then succeed where massage fails; but, if the contraction is the main cause of the delay, the light will have little beneficial effect. The application of radium probably has an effect similar to that of the ultra-violet rays.