The treatment of torticollis and of Bell's palsy (facial paralysis) have each been considered (see pp. 337 and 317).

Paralytic deformities of the upper extremity call for treatment designed to suit the nature of the paralysis. All that need be said here, and that only by way of emphasis, is that on no account whatsoever should any muscle affected with a flaccid paralysis be allowed to stretch.

Other deformities owe their origin to bony deformity, to adhesions or to pathological change in the soft tissues of some sort or another. In cases of bony deformity we may be asked to make the best of a bad job, such, for instance, as training a patient to use his scapula so as to reduce to a minimum the disability caused by ankylosis of the shoulder, or we may be asked to prepare the way for operation. The former involves the prescription of exercises, possibly "spacing" in a little massage during the early stages, and using it as a means of affording relief if an error is made in attempting to push the patient along too quickly.

Only two named deformities call for special notice. These are Dupuytren's contracture and Volkman's ischaemic contracture.

Dupuytren's contracture can, I firmly believe, be prevented from causing deformity if the trouble is detected early enough, and the patient is instructed to perform for a few minutes twice daily the exercise of hands clasping and turning spaced with a little deep kneading of the palm. Otherwise, when the deformity is fully established, no physical treatment seems to be really effective. Treatment after operation should proceed on general lines.

Massage treatment is constantly recommended as a remedy for ischaemic contracture. It is a slow and tedious affair and cannot be compared in efficacy or rapidity with treatment by splintage. But there is little doubt that massage can hasten the recovery when splintage is used. It should be applied whenever the splint is altered or readjusted in any way. Great care should be taken not to allow the structures that have been kept in a state of tension by the splint to contract appreciably during the treatment. At the same time it is wise to see that flexion is fully maintained whenever the patient attends for treatment.

For other cases, the use of the cock-up splint, of the cuff-and-collar, and of the glove and tapes has been referred to in earlier chapters.

It will be seen, therefore, that in the treatment of deformities massage plays but an accessory part at best. In this role it may be of the greatest possible service, and particularly before or just after operation. As time passes, however, its value decreases more and more rapidly, and the sooner it is supplanted altogether by exercises, the sooner the patient will recover.

A certain class of case which may have originated as a deformity or as the result of recent injury frequently finds its way into the massage-room sooner or later. This comprises the victims of cut tendons or of tenotomy. Treatment must depend entirely on what has been done and on what it is hoped may be effected. Roughly speaking, a divided tendon is joined together by fibrous tissue in about three weeks from the date of injury, and a further period of three weeks is required before this is converted into true tendon.

After accident or operation the limb is placed in position by the surgeon, and on this must depend the treatment to be meted out. Thus, if the tendon is kept by the surgeon in a position of complete relaxation, nothing may be done to move the joint upon which it acts. If, however, the position allows of movement which tends to relax the tendon still more, that movement with a return to the original position may be administered with safety. For instance, if the extensor tendon of the middle finger has been divided and the finger and wrist have been placed on a straight splint, extension of the wrist may be practised from the outset, and with this movement may be given a slight degree of flexion of the metacarpo-phalangeal joint. The inter-phalangeal joints may be moved more freely. No attempt to secure any flexion of the finger by forced movement is safe before six weeks have elapsed, though pure relaxed movement may be administered from the outset. If the patient was "put up" with the finger in full extension and the wrist in full dorsi-flexion, no movement should be given for three weeks. If a flexor tendon has been cut and the finger has been fixed in semi-flexion, it is safe forthwith to bend the finger further, provided that the wrist is flexed at the same time. Extension of the wrist should be left alone for three weeks, and thereafter the first attempts to extend it should be combined with flexion of the finger. No force or active movement against resistance is ever safe within the full six weeks.

If complete tenotomy has been performed in order that a tendon may be lengthened, then it is plainly our duty to perform every movement which may tend further to separate the two ends. This leads to the consideration of a natural and, so far as I know, unexplained phenomenon. Sometimes it would seem that nothing will induce the divided tendons of the hand to reunite, while nothing can prevent those of the foot from doing so. This indicates the contrast of treatment required. After tenotomy for a pes cavus or multiple hammer-toes mobilisation should be hastened with all possible speed. After suture of the tendons of the wrist we must move warily. In no class of case is skill in administering pure relaxed movement more urgently required.

Few cases, however, are more heart-breaking to deal with than those of tendon-suture when prolonged and strict immoblisation has been enforced. There is small cause for wonder in this when we remember that, during the immobilisation, not only are the united ends of the tendon joining together, but that the whole of their lateral surfaces are probably becoming equally firmly united to the tendon-sheath. Even if this does not occur, the site of suture will unite to that of the wound in the sheath no less firmly than will the sutured ends of the tendon to one another. In early relaxed movement we have the sole chance of averting these catastrophes.