A recently healed scar must, as was stated in the previous chapter, be treated with respect. For three weeks no movement may be performed which tends to separate the healing surfaces, and then only if repair has been carried out in the presence of asepsis.

There are two methods of dealing with scars that I have found of great service. One is the free application of "cupping" (see p. 370) to all the surrounding tissues, starting over healthy tissue and gradually approaching the damaged area. The other is to immobilise the scar by pressure, laterally or vertically, as far as possible, and then to call upon the patient to contract and relax the muscles underneath the scar. In other words, the patient is taught to loosen his scar by voluntary effort. He may also be taught to do this while the cupping is actually in progress, or the cup may be used to steady the superficial structures during the activity of the muscles. In all cases the cup must be drawn away firmly from the surface so as to exert the maximum tension; it must not be pushed on to the surface of the part. Finally, although these aids to loosening are of real and even great service, we are not doing the best for our patients unless we encourage to the uttermost the voluntary use of the muscles underlying a scar. Ordinary muscular activity will help to loosen a muscle involved in a scar quite as much as, if not more than, we can hope to do by other means.

However superficial it may appear to be, it is surprising how deeply the ramifications of an extensive scar may penetrate. Thus it never suffices to deal superficially with any obvious surface injury; it must always be considered as involving deeper structures until the contrary is proved. The question can be solved by rendering the skin and underlying structures as lax as possible and then by lateralising the whole area involved. Not infrequently a scar, which has no appearance of being adherent, will be found to dimple at one or more points, indicating the presence of some deep adhesion. Unless this is loosened first, any attempt to benefit the patient will be wasted. The first law in treatment should therefore be to relax the part to the uttermost, and then to lateralise all structures under the scar as freely as possible. This may be done by gripping the tissues on either side of the scar between fingers and thumb, or between the two thumbs or other parts of the hands. It is best to deal with these troublesome injuries by a process of slow and gradual stretching, and this can be effected by deep-stroking massage (usually employing the two thumbs), the pressure being exerted laterally. The stroke need not be a long one, and it should be performed so that the second thumb is exerting tension on the tissues before that exerted by the leading thumb has relaxed appreciably. If the pads of the thumbs do not afford a sufficient surface, the balls of the thumbs, or even the whole surface of the palms of the hands, may be used instead. When the process has continued for two or three minutes it may be reversed, and the pressure should then be exerted from the opposite side of the scar.

In this way the deepest ramifications are dealt with. The part is then placed in a position in which the underlying tissues are not quite so relaxed, and the process is repeated. This helps to loosen the less deep strands; while, when the structures are put in full tension, only the most superficial part of the scar is being dealt with.

A vibrator can often be used with good effect in loosening superficial scars, but only in rare cases should it be applied to the scar itself. It should be applied round the periphery, and should always be used so as to exert a lateralising effect on the scar.

Some masseurs prefer to use oil when dealing with scars. In massage for other conditions this is a question of personal habitude, but in the treatment of scars it is often to the patient's advantage that it should be used. The scaly appearance of some scars can be greatly improved by using oil, but this is only a superficial effect. How the use of oil can benefit scar tissue is a matter for pathological speculation. If the use of oil has any inherent power for good at all, the explanation thereof must be somewhat as follows: - Scar tissue is avascular and consists of fibrous tissue. The oil penetrates the superficial parts and insinuates itself between the fibres, which then form a kind of sheath around the oily globules. Thus the fibres are converted into the cell-wall of an oil-cell, which becomes transformed into a fat-cell, and so the fibrous tissue, in turn, becomes transformed from a pathological formation into a normal tissue. We know that a weakling baby can absorb oil through the skin and derive nourishment therefrom. Hence we are justified in assuming that the oil can be conveyed from the surface through these artificially made "fat-cells" to the deeper parts of the scar. Suppleness is thus restored, and the substitution of normal tissue for pathological fibrous bands takes place. There seems to be no other explanation possible to account for the claim so often made that massage, using oil as a lubricant, benefits scars so much more readily than if powder is used. At the same time the explanation is wildly speculative; and, until definite histological investigation has established it as a fact, I prefer to believe that it is the rubbing (and this alone) that does the good, and that any improvement noted in the deeper parts of the scar as the result of substituting oil for powder is due to improvement of technique thereby. A distinction must clearly be drawn between apparent surface change for the better and actual deep change. As already stated, the former is frequently noticeable. Great skill is required in dealing with even the most insensitive of scars, and a patient will often do better if the whole treatment is performed in hot water. The eau courante, or whirlpool, bath has been greatly extolled in this connection since it was installed at the Grand Palais in Paris, and has become very fashionable in this country. The hot-air bath has a great reputation in the treatment of scars, and is often of service as a preliminary to treatment. Even better is massage under a radiant heat lamp. Massage in a bath of hot water or under the hot tap renders manipulation of a painful scar less difficult, and the eau courante bath tends still further to minimise the difficulty of dealing with a sensitive scar. The only possible explanation of the benefit to be derived from the swirl of water is that some beneficial reflex is set up. Experience has yet to prove that this can be excited more efficiently by movement of the water than by massage. Its advocates do not wish to supplant massage by its use, but only to use it as an adjunct. If massage treatment is crude, or if the main laws of massage treatment are disregarded, this bath will be found of inestimable service; if massage treatment is efficient, its use will prove a valuable accessory.