In the previous lectures I have endeavoured to show the way in which stiffness and other disabilities of the joints arising from fractures and other injuries may be prevented. My present purpose is to indicate the rules which should be observed in the management of stiff joints generally upon principles which are rational, as opposed to the casual methods which have been hitherto not uncommonly used. Increased intelligent appreciation of the causes which lead to stiffness of articulations, and of the circumstances which influence them, has fortunately led to a more rational understanding among surgeons generally, and has enabled the ordinary practitioner to deal with these conditions in a manner which was quite unappreciated a few years ago. In using the term ' rational management' I mean management based upon reasonable principles, as opposed to the happy-go-lucky methods of the so-called bone-setters, who, until recently, have practically had the monopoly of the management of cases of this kind. The term 'stiff joint' I wish to limit for my present purpose to those joints which are fixed by fibrous adhesions or matting around or in the vicinity of the articulation; cases of bony ankylosis of course do not come under consideration in the present discussion.

Stiffness in a joint, therefore, in the sense in which I am now speaking, may be due to adhesions inside the articulation ; to stiffening of the capsule by adhesion, or matting of the parts immediately around it; to temporary muscular rigidity, or to permanent rigidity of muscles, from physiological shortening, and finally to adhesion of muscles (e.g. in fracture) at a point more or less remote from the articulation. The first object in any case in which breaking down ' of a stiff joint is contemplated is to ascertain whether there is, or whether there is not, bony ankylosis. This can generally be easily ascertained by examination under an anaesthetic, and as a rule without an anaesthetic, especially if the x-rays be used as a help. But the x-rays in themselves are apt to be extremely deceptive, and will sometimes show a joint to be apparently ankylosed which, under an anaesthetic, may, with a little discreet manipulation, be made to bend almost to its complete extent. On the other hand, I have seen a skiagram showing a joint apparently sound and in good working condition which, when examined after amputation, was found to be absolutely ankylosed by buttresses of bone. The evidence of the x-rays, therefore, in the conditions which I am now considering, must not be regarded as above suspicion.