The massage treatment of the greater number of orthopaedic cases has already been considered under various headings. There remains, however, one large group of cases which calls for special consideration. These cases are those in which external splintage is used as an essential part of the restorative process.

We have seen how large a part is played by massage in what may be called "medical" cases, and also that it often plays an essential part in the treatment of recent injury. But in the former it may frequently be that other treatment (i.e., by mobilisation, active or passive) is only an accessory to the massage; in the latter the mobilisation treatment is no less essential than the massage which precedes it. In fact, in certain somewhat isolated cases, the importance of the massage treatment dwindles into insignificance. So it is also in most orthopaedic work. True we are sometimes called upon to treat cases which amount to nothing more or less than cases of recent injury, cases of recent arthroplasty furnish a good example, and these of course call for massage as a preliminary to mobilisation. But in much of the ordinary run of orthopaedic work the place of massage gradually passes more and more into the background, compared to that occupied by mobilisation in its various forms, the chief being the active variety.

In all orthopaedic work there is a common danger that a grievous fallacy may creep into the minds of the patient and of those responsible for his treatment. I have already referred to it when speaking of the use of Zander and Pendulum apparatus. The fallacy is this: The patient comes to be cured, and it only too frequently happens that the surgeon, the masseur and the electro-therapist alike, either by tacit consent or open declaration, tend to inspire the delusion that they, one or other or all, can effect the cure. Almost invariably the only person in whose power rests the decision between success and failure is left out of consideration. The surgeon can render cure possible, the physico-therapist can loosen, teach and train; but without co-operation and good-will on the part of the patient the most brilliant surgery and most skilful treatment are totally unavailing. It is the patient, in these cases, who must, in the long run, cure himself; all we have to do is to help him to effect his cure in the shortest possible time with the minimum of pain and inconvenience.

Co-operation between the surgeon and the masseur is the second essential to success. Take, for instance, the treatment of a case of a simple fracture of femur. When making the choice of a splint and while attending to its application, the surgeon should constantly bear in mind what physico-thera-peutical methods he intends to employ and should act accordingly. For instance, it is useless for him to prescribe early flexion of the knee while the limb rests in a Thomas' splint if the foot-piece has been applied so as to prevent this. On the other hand, if he desires that only a few degrees of movement should be administered, the position of the foot-support is immaterial.

Then, too, during the later stages, co-operation is no less important. In cases of compound fracture of femur it is a common event for union to be greatly delayed. After weeks - more often it is a question of several months - of confinement to bed, the patient is allowed up in a walking calliper. Unless the surgeon co-operates with the masseur, recovery will be unnecessarily slow and tedious. In the first place the onset of oedema is more or less certain unless care is taken to prevent it. For (putting aside the inevitable disorganisation in the vasomotor system of the limb, as the result of the original injury, prolonged rest, and elevation) the one great preventative agent against the formation of oedema is woefully lacking, namely, voluntary contraction of the muscles. True, intelligent training in muscular activity during the early stages will do much to counteract this tendency to inactivity on the part of the muscles of the limb; yet the application of the calliper cannot but serve as a more or less inhibitory agent. Hence it comes about that, delighting in his newly-gained freedom, the patient remains "sitting up" most of the day with an occasional short walk. No amount of early training will keep the muscles in activity in the former position to an extent which will ensure that oedema shall not form sooner or later, the limb being dependent. The more it forms the less muscular activity will there be, and so a vicious circle is started. And it is folly to expect that the onset of oedema can be controlled, save only to a limited extent, by massage. True, we can help by mechanical means to assist the venous and lymphatic circulation; and, by reflex response to mechanical stimulation, we can help in maintaining the tone of the unstriped muscles in the arterioles; but we can only do these things for a limited space of time - say, half an hour - whereas gravity will be at work all the rest of the day, whenever the limb is dependent, opposing the venous and lymphatic circulation. Against this inimical influence continuous activity of the muscles throughout the limb can alone prove efficacious. And this, from the very nature of things, is at first impossible; the most we can expect is spasmodic bouts of activity.

It is the surgeon's duty, therefore, to see that the patient, through ignorance, does not render the masseur's labour of no avail. He must warn the patient that the onset of oedema is certain, with all its attendant disadvantages - discomfort, inhibition of muscular activity, circulatory disturbance, slow repair, and tedious recovery - unless he is content to regain his freedom by slow stages. He must not be allowed to "sit up" all day at first; half an hour the first day, two separate half hours the next, three the third, and then an extra quarter of an hour added on to each of the three periods every day would be a reasonable rate of progress. The patient will then be sitting up six hours a day at the end of nine days, and all the time he is not sitting up, the limb must be well elevated; when it is dependent voluntary muscular activity must be as constant as possible. The onset of oedema is not an indication for an increase in massage: it cries for an increased dose of elevation. There is only one person who can really control this part of the treatment satisfactorily - the combination of rest and activity - and that is the patient himself. Let us see, then, that he understands the principle, and, whether he co-operates or not, we have done our best. Leave him in ignorance, and we cannot make the same claim. The principle underlies the treatment of every case of oedema, even of the upper extremity.