Perhaps the most troublesome form of muscle injury is that which befalls the erector spinae or one of the small muscles in the back. The trouble is not that the injury is necessarily severe; but because, if treatment is not immediate and efficient, pain may prove most intractable and crippling. There seems to be a strong tendency for a neurotic element to creep in, and then the patient's condition is truly lamentable. Firm kneading to prevent effusion, or to disperse it if formed, should constitute immediate treatment; and mobilisation, which of necessity must be chiefly active, should be prescribed with as little delay as possible.

If a tendon is severely torn so that few fibres only remain intact, the surgeon will be wise if he fixes the joints concerned during the period of repair. If massage is ordered, no movement of any joint should be allowed which cannot be controlled by the patient to the extent of fully restoring the position from which the movement started. Otherwise repair may be impeded. Rupture of the extensor tendons of the inter-phalangeal joints is by no means uncommon. Even when rupture is apparently complete it is often surprising how perfect recovery may follow the use of splintage applied to the posterior aspect of the joint. This may be applied only to the joint concerned and allows of a very considerable freedom in use.

Sometimes the deep fascia over a muscle is torn and the muscle fibres tend to protrude through the rent during contraction - a hernia of muscle. This is a trivial accident, but may cause much discomfort, and the "lump" may produce a marked psychical effect. Recovery depends on the repair of the sheath, and, if repair has commenced, it may be completely undone by a single contraction while the orifice is not guarded. Thus no contraction of the muscle must be allowed unless a hand or bandage is placed over the whole area of injury. This precaution taken, mobilisation may be administered and prescribed freely.

It is not very often that the masseur is asked to deal with a simple bruise, yet the relief that can be given by skilled massage is immense and the period of discomfort can be greatly shortened. Treatment should be given as for a severe sprain: surface stroking (avoiding the injured area at first and gradually encroaching on it later) is succeeded by deep stroking, and this in turn by local kneading. The kneading is best performed by placing the whole palm of the hand firmly over the site of injury and then by imparting a circular movement to the hand. Surface stroking terminates the seance.

If a nerve is injured (the ulnar nerve frequently suffers from bruises), treatment follows on similar lines; but care must be taken to avoid any movement or pressure that causes pain. One of the dangers of treatment is that pain can be greatly relieved, and the temptation to do more and give prolonged local treatment may be great. This is a mistake; and a frequent result is that some two or three hours later the patient is worse off than if he had never been treated. Other nerve injuries will be dealt with in subsequent chapters (see Chapters XXIII. to XXV.).

Post-operative treatment must be considered, from the massage point of view, as entirely different to the treatment of other recent injuries. The difference is this: the surgeon is almost certain to issue definite instructions as to what he wishes to be done. Hence little need be said here, save to insist once more that all massage movements must be slow, gentle, rhythmical, and devoid of pain, while any form of mobilisation must equally be painless.

Operation scars of recent date must always be treated with respect; and care must be taken not to tear the granulation tissue which holds the edges of the wound together. Hence all movements of massage should tend to press the edges towards each other; and, if any movement performed during the mobilisation tends to drag them apart, the granulation tissue must be adequately supported and juxtaposition of the edges must be maintained. A scar is not organised firmly for about three weeks.

It not infrequently happens that a surgeon breaks down adhesions in a joint and then orders massage and mobilisation to commence forthwith. It is preposterous that such orders should be given without informing the masseur as to the amount of movement that was secured under the anaesthetic, and as to the amount of difficulty experienced. Yet this often happens, and the masseur is left to judge as best he may as to the extent of "injury" inflicted by the operation. The amount of pain and the difficulty in relieving it are fair guides. Surgeons usually expect any movement which has been performed under the anaesthetic to be performed at the first massage seance after operation. This is doubtless ideal but is not often easy, particularly if the surgeon has made a mistake and done more than was desirable. Also it is most difficult to know exactly when to "break down a joint," or even to judge what joints should or should not be treated in this manner. The ideal method of ensuring satisfactory after-treatment would be for the masseur to be present at the operation, and it should always be arranged if possible. If this prove to be impracticable, then undoubtedly explicit instructions should be given, and if "full movement" is ordered it must be given. Should it cause great pain, the fact must be reported before the movement is repeated. The best plan for all concerned is to aim at securing on the third day the full range of movement that the manipulation has rendered possible. If, after prolonged massage and patient attempts to secure this result, it becomes obvious that movement is more limited than before the operation, we may be sure that something is wrong - either that the operation should not have been performed or that too much has been attempted.

After any such operation it is almost impossible to adhere too strictly to the rule of painless movement, and therefore some guide is necessary as to the amount of pain that it is permissible to inflict. A good working law is that if pain can be relieved by massage all is well; if pain ceases within half an hour of the limb being placed at rest no deleterious result need be feared. If, on the other hand, pain is persistent, if swelling or synovitis do not rapidly subside, or if there is any increase in the difficulty of securing movement, or of pain during movement, then too much is being attempted. The principles underlying the administration of forced movement under an anaesthetic are dealt with in a subsequent chapter (see Chapter XVII (Forced Movement - "Bone-Setting").).

One word of warning is needed about the treatment of limbs after a bone has been plated. There is a tendency to believe that the plate will act so efficiently as an internal splint that no disturbance of the fragments need be feared. This is a most dangerous delusion. After all plating operations no less care should be exerted to avoid placing any lateral strain on the site of fracture than if the plate were not present. At operation the screws doubtless "bite" firmly; but this entails pressure on the bone, and in a few days the "bite" is far less firm than at first. Strain at the site of fracture may then serve to loosen the screws and prejudice the whole success of the operation.

In all post-operative treatment, massage should aim at relieving pain and restoring circulation. Mobilisation should aim at teaching the muscles to contract, whether movement is possible or not. It is usual to wait for three or four days to elapse before beginning post-operative treatment. This suffices as a rule to show whether suppuration is calculated to supervene or not. Should it occur before the masseur sees the case he cannot be blamed for it. But there is really no reason why treatment should not begin after, say, twenty-four hours. When all is said and done, operation is only one form of recent injury.

If massage is ordered while a wound is still septic, special precautions are necessary. The author recalls the case of a nurse who developed blood-poisoning as the result of a prick on her thumb while doing district maternity work. Massage was commenced while there were still six drainage tubes in the limb, the top one being in the axilla. Not only did the application of massage save many doses of morphia, but complete use was restored to hand and arm except for the interphalangeal joint of the thumb, where the tendon had actually sloughed away. In so severe a case nothing but surface stroking is permissible, and mobilisation must be painless. The presence of sepsis is no contra-indication, if this law is respected. As Lucas-Cham-pionniere pointed out, many years ago, the presence of an open wound or even of sepsis is no contra-indication to skilled massage and mobilisation. Far otherwise indeed: the treatment is essential if subsequent disability from scarring and adhesions is to be reduced as far as possible.

When the sepsis is localised the case is simplified, but this very fact enhances the danger in one direction. If a knee-joint, for example, is septic and massage is ordered, it is right and proper that surface stroking should be succeeded by massage to aid the circulation. A wide berth must, however, be given to the area of sepsis, otherwise there will be great danger of breaking off an embolus in one of the veins. It is true that any area where thrombosis is present is tender to the touch, and so, if the massage is painless, there is really little risk. But the patient is sure to be in discomfort and probably in pain, and the slight additional pain due to gentle massage may be accepted without complaint or even with actual relief. "It is a pleasant sort of ache," the patient may say. If no sepsis is present, this "pleasant pain" may be disregarded; but in the presence of sepsis it must be regarded as a serious danger-signal.

Throughout this book treatment by exercises receives for the most part but scant notice - so, too, must treatment by electrical methods. It is not intended to belittle the value of either, but each requires such special consideration that a book on massage cannot be made to cover the ground.

Short reference must, however, be made to the use of electricity in the treatment of injury, and particularly to the treatment known as "Graduated Contraction." 1 Its value is seen in four directions. First, it provides a means of preventing muscular wasting after injury, and, second, of exercising a muscle without moving the joints upon which it acts. Third, it enables us to exercise any individual muscle which happens to have suffered injury out of proportion to that sustained by its synergists, and an example has been given when referring to rider's strain. Fourth, it affords a means of exercising any muscle, which may have wasted to such an extent that the power of voluntary contraction is too poor to allow the patient to re-develop it by exercise with reasonable rapidity. The wasting of the quadriceps after injury provides a dual example. Not infrequently the muscle is so wasted that, if its re-development is left to the patient's own efforts, recovery is likely to be tedious and prolonged. Also, unless the power of voluntary contraction is well maintained, it is a most difficult task to exercise the lower fibres of the vastus internus as suggested on p. 183. It is in cases of this type that treatment by graduated contraction finds its metier.

1 For a full account of this method of treatment see "Treatment of Joint and Muscle Injuries," by W. Rowley Bristow, Oxford Medical Publications.