If the patient is seen within a few hours after dislocation of the shoulder, to attempt to secure reduction under the influence of massage is the correct course to adopt. If it succeeds, there is less likelihood of further damage being done to the soft parts than if reduction is performed under an anaesthetic, particularly under gas. If it fails, reduction under an anaesthetic is rendered a no less, and probably a more, simple procedure. On one occasion I was able to reduce a sub-coracoid dislocation under the influence of massage when two attempts at reduction under gas had failed. The technique is simple. The patient is treated sitting in the position advocated for the treatment of a fracture through the shaft of the humerus (see Fig. 74, p. 147). The elbow is flexed to a right angle and the hand is supported on a sling across the chest, and not as shown in the illustration. Massage begins over the side of the neck, as shown in Figs. 132 and 133, on p. 298. The back of the neck is then dealt with in the same way, and finally the pectoral region. The position shown in Fig. 74 is next adopted, but the forearm still rests across the body, and the left hand secures a firm grip upon the forearm near the elbow and exerts a constant pressure downwards in the long axis of the humerus. Meanwhile massage is applied, according to the evidence of persisting muscular spasm, to the upper arm, or shoulder-girdle muscles, or chest and back. Slowly the spasm of the muscles that control the movements of the joint relaxes and, in fifteen to twenty minutes from the outset of treatment, reduction may be anticipated. If it becomes evident that the muscle spasm is not relaxing a few minutes after the tension begins, the patient should be placed in the recumbent position. When once reduction has been effected there could be no greater error than to enforce complete rest for the joint. This is probably the most fertile source of recurrence. The stability of the joint depends entirely on the muscles that control its movement, and, if these muscles are allowed to waste, instability of the joint is inevitable. Everything possible, therefore, must be done to maintain their strength and tone. Massage alone can help, it is true, but muscle activity and work can alone prevent loss in both respects. If reduction has been effected without delay the amount of wasting is negligible, and, as the stability of the joint depends on this factor, it follows that the chance of immediate recurrence is not great. If the patient's clothes are split up in front so that he can put on all his things as he puts on an ordinary jacket, he may dress immediately after his treatment, carry his hand in a sling, and begin ordinary light underhand use of his arm from the outset. He should be encouraged to move his shoulder freely, provided he does not abduct above the horizontal. As the result of this treatment many patients pronounce themselves cured in seven to ten days, but this is probably incorrect. They are probably not as safe after so short a time as they were before the accident, but the difference is not great, and, barring accidents, all should go well. It must be clearly understood that it is safer to administer movement freely during the first week after dislocation than during the third, if the joint has been immo-' bilised meanwhile. Exercises should be administered to strengthen the pectoralis major, sub-scapularis, and the two spinati, but special attention should always be paid to maintaining the strength of the deltoid.

One form of "sprain" of the shoulder calls for special mention. It is the so-called "stubbed shoulder." This is seen occasionally as a sequel to Colles' fracture, and also as the result of a fall on the point of the shoulder. The nature of the injury is that the head of the humerus is driven with violence against the glenoid. The articular cartilage lining the latter is injured, and, being avascular, it can be repaired only by vessels creeping in from the periphery. This corresponds to the phenomena witnessed after contusion of the cornea. It is a process that takes time, and it is only when the injured patch becomes vascularised that pain of any severity is noticed. This occurs usually about three weeks after accident. The temptation is to regard the shoulder injury as one of such long standing that movement should be forcibly restored. It may even be attempted under an anaesthetic. The result is invariably disappointing, as, instead of hastening recovery, it must inevitably bruise and injure the delicate vessels that nature has formed to hasten repair. The only treatment is absolute rest for about three weeks, though massage for the rest of the limb will maintain its nutrition and mobility. It may be asked, "How is a masseur to be expected to know this condition and to avoid doing injury?" The answer is simple. Here, as in all other cases of injury, no harm will arise if the golden laws of treatment are observed: first, that any relaxed movement may be administered only if it is painless; second, if range of movement one day is less than the previous day, too much movement has been given and the dose therefore must be reduced; third, any increase of pain on voluntary movement, or any increasing loss of mobility, are contra-indications to the continuation of mobilisation. Respect for these laws means that no injury will be done; neglect invites catastrophe. The answer to our question then is this: there is no need for a masseur to be a diagnostician; he should know and recognise danger-signals, and should not be afraid to admit having done too much one day and to reduce the dose accordingly. It is no part of his responsibility to decide what has happened, that is the surgeon's work: his duty is to report to him in the event of untoward symptoms being noticed.

One of the dangers encountered in treating dislocation of the elbow has already been dealt with when considering fractures round the elbow-joint (see p. 149). It was then told how, in the absence of all X-ray evidence of injury to bone, there is a tendency to the outpouring of a vast formation of new bone. Massage to restore vaso-motor balance and to assist the absorption of swelling should be given, but movement must be very guarded in the presence of local swelling which may indicate blood-clot. There is another danger. The injury is severe, all the structures in front of the joint are severely torn, and therefore have to be repaired. This is done by the formation of granulation tissue. If this is broken down again when once it is formed, not only does blood escape from the torn vessels of which it consists - thus producing the source of danger we have already seen must be avoided - but a stimulus is given to the formation of more granulation tissue. No matter how much is laid down it will in the end organise into fibrous tissue. If there is no excess, this will serve only to repair the damaged structures; if it is excessive, adhesions will also form. Suppose, then, that treatment is conducted in the fully-flexed position, there would seem to be two alternatives: first, to perform no movement, in which case it is certain that the bands which effect the repair will be too short to allow movement in the future, or, second, to administer movement and chance doing so to excess. It is essential, therefore, to know what can be done with safety. Obedience to the laws just recapitulated will avert disaster, but here it is wise to state once more in addition, that relaxed movement must be performed to its full limit once and once only, no matter how small the range may be. Turning the patient's forearm into a sort of pump-handle is absolutely prohibited, and it is only when the range of movement to be performed has considerably increased that to and fro movement through the sub-maximal range is permissible. All sprains of the elbow should be treated cautiously and on lines similar to those advocated for fracture near the elbow, or for dislocation. As the gravity of the injury is obviously less severe, treatment may be advanced with corresponding rapidity, but the main laws of treatment must be regarded scrupulously. No injury to the elbow-joint should ever be treated light-heartedly. Care and caution never produce untoward results, their neglect may lead to disaster.