It is usual in text-books on massage to devote a separate chapter to the treatment of deformities, and I have chosen to follow the usual practice in the hope that I may be able to emphasise the fact that, in their treatment, massage plays but a small part. It may, however, serve as an important accessory.

The question to be solved is how best we may assist the orthopaedic surgeon. We may be called upon to prepare the way for operation. This usually means that massage is required to promote the nutrition of the part. The laws laid down elsewhere should serve as an efficient guide.

Occasionally massage is invoked to aid in the prognosis of a case. When this is done it is essential that the surgeon in charge should give detailed instructions as to the manner in which he wishes the case to be treated and state the raison d' etre for the instructions given. His wishes must be obeyed loyally; beyond this it is impossible to offer advice. If it is desired that massage should test as far as possible whether past sepsis is sufficiently overcome to render operation safe, the masseur must "go all out." A prolonged dose of cupping will usually betray the presence of latent sepsis in the skin. Otherwise the area of operation should be subjected to vigorous kneading, friction and vibration. Though he should not intend actually to produce bruising, the masseur should not be blamed if he oversteps the mark slightly. The test is rough and ready and not too reliable, as we cannot by massage break up an encysted focus of infection which the surgeon may cut across. It is, however, the best we have, and has saved many patients from premature operation.

After operation, massage may be prescribed to restore or to maintain the circulation, or to prepare the patient for a course of exercises and to assist him in their performance. Again, the general rules laid down elsewhere should prove sufficient guide.

Either before or after operation it may be our duty to loosen scars, to stretch adhesions, restore mobility, and so on. After operation our treatment must always have in view the sole end - restoration of function. This must depend on exercise, and on exercise alone. Massage can merely assist. It is only possible here to lay down general rules for treatment. The most important are, first, that if massage is given at all, the whole limb, or at least the whole segment of the limb, must be treated and not only that which is adjacent to the site of operation. Indeed, this should usually be the last part of the whole limb that we should treat. Any part of the limb which can be kept nourished by active exercise requires no massage, except in so far as it may serve as an incentive to active movement.

Then, second, if the surgeon has endeavoured to stretch some structure, the table of exercises should always be framed with a due regard to his intentions. This means that every exercise should be designed to lay further stress upon the structures which he has already tried to stretch, and to contract or shorten those he has tried to release.

In the treatment of feet, for example, if the surgeon has wrenched a flat-foot and maintained the correction in a plaster cast, it is obviously acting contrary to his wishes if exercises are prescribed for the patient that can by any possible means lay strain on the plantar ligaments. Thus the ordinary heels-raising-knee-bending exercise with the toes turned out is absolutely contra-indicated till a very advanced stage of treatment has been reached. Co-ordination exercises, walking on the outer edges of the feet, ordinary walking in boots with the inner side of the heel raised, tip-toe walking with the toes turned in, lessons in standing with the feet parallel and crossed with the weight on the outer borders when sitting, quadriceps training and exercises - these are all safe and legitimate. On the other hand, if an attempt has been made to flatten out a case of pes cavus, the very opposite line of treatment should be followed. The patient should be instructed in heel-walking and to perform exercises in the lunge position, while heelraising exercises of whatever description should be postponed till the last.

In cases of hallux rigidus or valgus massage can prepare the way for operation, and can assist greatly if "spaced" between the various exercises afterwards. It is possible also to assist in the maintenance of the mobility of the joint. The ordinary laws of administering relaxed movements must be obeyed, and, speaking generally, the earlier movement is started after operation the better is the result. It is often of service to put a certain amount of longitudinal tension on the toe while performing the movements. It is essential in these cases to know whether the surgeon has divided the bone completely or not at the operation. In the former instance, as there is a complete fracture, progress should be more slow than in the latter, where the fracture (if present at all) is of the greenstick variety.

In the post-operative treatment of hammer-toes it is vital that we should be told whether the surgeon is aiming at an ankylosis, or wishes to secure a movable joint. In the former case exercises alone should be given when union is firmly consolidated; in the latter, the joint should be kept supple in so far as full extension is concerned. No attempt to secure any marked degree of flexion should be made.

But it is only the very severe forms of foot deformity which are subjected to operation. There are countless sufferers from foot trouble of greater or less severity for whom no surgeon would perform an operation. Yet the lives of these patients may be rendered miserable by their feet, their occupation endangered or rendered unduly laborious and painful; or they may be condemned to a sedentary life when yearning for activity. Holidays, too, are deprived of nearly all their pleasure, and sport of all kinds is prohibited. These patients have only one hope of relief, and this rests on the provision of proper footgear and on skilled re-education. No amount of treatment by "massage and exercises" can ever help a patient who is not properly shod. The first essential, therefore, is to know exactly what this means.