By

Sir Robert Jones, K.B.E., C.B., Maj.-Gen. A.M.S.

Director of Special Military Surgery.

The value of massage as an aid to the orthopaedic treatment of our wounded is now too well established to require defence. It cannot, however, be denied that many of the ideas prevalent as to the methods of its use are often very vague, and surgeons who have made a close enough study of the subject to give definite directions to the masseuse are still fewer than they should be.

In these pages we have an exposition of his own observations and practice by a physician, an acknowledged master, whose enthusiasm for his subject is tempered by a wide clinical experience of success and of failure.

It cannot be too frequently stated that treatment by massage must be directed and controlled by the surgeon treating the case. There is no half-way house between success and failure: massage either does good, or it does harm. The harm done may not be to the local injury from which the patient is suffering, but to his psychological attitude towards his own case. In hospitals which I visit it is common to meet patients who say they have had months of massage and are no better. There could be no stronger condemnation of the system by which the massage is controlled.

We still frequently find that cases are sent to the massage department with no detailed account of what has been done by the surgeon, of the plan by which he has been trying to restore function to a disabled limb, or of the part he wishes massage to play in the future course of his treatment. The responsibility rests on the surgeon, not on the masseuse. Success in treatment depends on loyalty between surgeon and masseur or masseuse: loyalty on the part of the surgeon in giving precise explanations of what he wishes, loyalty on the part of the masseuse in faithfully carrying out those instructions and immediately reporting any condition which she may observe.

When this close alliance is maintained, massage may be successfully employed as a preliminary to, as a concomitant with, and as a sequel to active surgical treatment. As a preliminary to surgical treatment, it may be of diagnostic value when the surgeon wishes to perform some operation, but the cicatrices from previous suppuration are an impediment to a successful operation. He may ask the masseuse to loosen the scars by delicate manipulation, but must warn her that the least sign of inflammatory reaction must be reported, for nothing except forced movement will arouse the activity of a latent focus of inflammatory mischief more quickly than massage. A preliminary course of massage will therefore serve to indicate whether the case is ready for surgical interference or not. It also prepares the way for operation and may even render it possible.

As a concomitant to surgical treatment, massage may be employed to alleviate pain, reduce oedema, assist circulation, and promote the nutrition of tissues.

As a sequel to operative treatment, it serves to restore the nutrition of tissues, and initiate the patient into an appreciation of muscle sense and movement lost by months of disuse following a severe septic injury, thus paving the way to recovery of voluntary muscle action, which is the ultimate aim of all orthopaedic treatment.

In the following pages the constant reference to the use of "exercises" should serve to emphasise that massage should rarely constitute the whole of the treatment. Exercises should almost invariably find some place, and their skilful prescription is an art which calls for long, careful, and special study.

The responsibility of the masseuse to the surgeon must be based on a proper instruction in the idea or plan of treatment he is following. The masseuse must be technically well trained in manipulation, must have a sense of loyalty to the plan she is asked to follow, but must also have an intuitive sympathy with the patient, quick to appreciate when her manipulation is causing pain and may be harmful, quick to detect signs of inflammatory reaction and at once to report them, and most of all, quick to detect signs of recovery and to point them out to the patient, thus rousing in him an interest in his own progress, which is half the battle, for the psychological element must be kept in view. Without this last gift of intuitive sympathy the most perfect technical knowledge is useless. The convalescence also may be long and tedious, but in the pages which follow the reasons for perseverance are amply illustrated.

Robert Jones.