Sir Robert Jones has devised a scheme for encouraging what he calls "gymnastics of the arterioles," which consists of contrast bathing, the limb being plunged alternately into hot and cold baths. It is not a pleasant treatment, but the patient soon accustoms himself to it, and there are cases where it has seemed greatly to assist progress. The use of the paraffin bath as a preliminary to massage for these conditions is now well established and its value proven beyond all question. It should be free from danger, if care is taken to ensure that there is no sensory disturbance in the part. Otherwise serious blistering may be encountered.

The whole idea of all these treatments is to secure beneficial effect through the vascular supply of the limb, and the repair of scar tissue requires an efficient supply of blood no less than do other reparative processes. General vaso-dilatation due to heat alone does not seem to meet the requirements, although as a preliminary to exercise of a stiff limb it may help considerably. Anyone, who is stiff after a long day "cross-country" and takes a hot bath, will bear testimony to this fact. The danger of the use of heat and other baths is that it may serve to cloak inefficiency in massage. But for the end in view, the vascularisation of a local area, no forms of heat treatment can hope to compete with ionisation. Here it is probable that the benefit is derived from the hyperaemia produced and not from the action of any particular ion, and valuable assistance might be anticipated from it. In this I have been disappointed; and, though my conclusions will not be universally accepted, I can only say that, in my own experience, I have yet to see any definite evidence that a scar which fails to loosen as the result of massage treatment will do so when ionisation is added; or, conversely, that one which is loosening satisfactorily will do so more rapidly when ionisation is given as well. Of the loosening effect of X-rays on scar tissue I have no experience, but I can bear limited testimony to the efficacy of radium. My attention was first called to its use by Capt. Stevenson, and since then I have watched the progress of several cases treated for me by Dr. Lynham at the Radium Institute. Capt. Stevenson summarises its action as follows: -

"1. Radium has a distinct sphere of usefulness in the treatment of scar tissue and fibrous adhesions.

"2. It is a valuable adjunct to other methods of orthopaedic treatment, especially by shortening their duration.

"3. Its effect is rapid, sometimes immediate.

"4. It softens and mobilises scar tissue.

"5. It appears to facilitate subsequent removal of the scar by the knife.

"6. It enables structures, like tendons adherent to the scar, to free themselves.

"7. By loosening tendons and stiff joints it improves the functional power of the part.

"8. It possesses the advantage of acting, to some extent, as an innocuous local anaesthetic for about a week.

"9. It is particularly useful in treating scars and adhesions in the hands and fingers.

"10. It is easily applied to the surface of the skin, and by this method causes no inconvenience to the patient.

"11. To obtain the best results a single large dose is necessary.

"12. The dose should not be so great as to produce inflammation of the skin.

"13. With suitable dosage it appears to produce no ill effects.

"14. In small doses it appears to hasten the healing of wounds and to allay the painful inhibitory effects of the products of inflammation."

From my own limited experience I would add that the greatest caution must be used in prescribing dosage, as radium burns are disastrous. They are always indolent and often painful. Radium should never be applied if metal is still present in the depths of the wound, even though this is healed. Also undue expectations will lead to disappointment. For instance, the increased range in movement noticeable after the application of radium for a stiff finger may not be more than 5°, and the improvement, though present and therefore valuable, may well be overlooked on superficial observation. Many applications may be necessary, extending over many months, before any very marked change is noted. In some cases the action seems to be purely negative. But, taken as a whole, I think it safe to say that the general condition of the part treated is often considerably improved; mobility (e.g., of a stiff finger) is sometimes very slightly improved; the part often "feels more natural" to the patient, and is therefore used more freely; sometimes manipulation is rendered easier; and scars, beyond all question, do tend to loosen in a manner that surpasses that due to any other method of treatment with which I am acquainted. Progress, however, is often lamentably slow. But the dosage must be carefully guarded.

One lesson at least may be learnt from the advocacy of hot air, hot water, the eau courante bath or the paraffin bath as a preliminary to massage treatment, namely, that to mete out to a scar treatment that is purely local is inefficient. The whole of a limb, or at the very least the whole of a segment of a limb, should receive attention before any attempt is made at purely local treatment. Moreover, the massage used should consist of the stroking for surface reflex first, then general treatment to aid circulation, and finally local treatment.

If a nerve is caught in a scar, the benefit to be derived from massage is always problematical. Three methods of attack seem to be of service. The first should always be used, namely, surface stroking, followed by deep stroking. Gentle kneading of the area around the scar should follow, provided no pain is felt during the manipulations. As sensitiveness decreases the painful area is gradually approached. The second device is to place the palm of the hand firmly over the sensitive area and impart to it a circular movement, using the hand as a sort of millstone - the mouvement en meule of Lucas-Championniere. It often happens that a surface, which the patient cannot bear to be touched in any other way, can be freely manipulated thus. The third method is the use of a mechanical vibrator - a small hand machine run by electricity being almost essential. A "brush-pad" should be used, and it should be applied freely to those areas round the scar in which sensation is normal. The painful area is then gradually approached, and the actual surface itself can often be treated directly by transmitting the vibrations through the hand of the operator. How the vibration acts is not very clear, but remarkable results may sometimes be noted. The most probable explanation is that the shaking is sufficiently severe to loosen all small peri-neuritic adhesions, but of insufficient amplitude to cause pain. Moreover, as the vibrations are transmitted from a distance during the early stages, any stretching that takes place must be performed by very gradual stages. If there are three ways in which a painful scar may be treated, there is one in which it should not, namely, by any process of pulling or pushing directly applied to it, or of pressure over any selected portion.