In true anchylosis of joints, in which formation of bone or connective tissue and cartilage have caused a growing together of the articular surfaces of the joints, medical gymnastics and massage play no great part in the actual treatment of the joint. No treatment, whether manual or mechanical, can make a joint movable when there is no mobility in it; muscle gymnastics can accomplish just as little for the muscles when the joint upon which they work has completely lost its function. It is equally pointless to try by massage to keep in condition those muscles that are and must remain functionless. The only indication for medical gymnastics that is found in cases of anchylosis has to do, not with the anchy-losed joint itself, but with the treatment of joints in close proximity to it. Through development of the utmost power of movement of the neighbouring joints by means of exercise the functions of a limb weakened by a defective joint can not infrequently be considerably improved, resulting in a kind of compensation to the anchylosis. It may be pointed out that the mobility of a limb necessary for the everyday functions of life certainly improves more by the patient's own continual efforts to perform the greatest possible movement and work with the anchylosed extremity than by short daily seances of medical gymnastics and massage. It may well be, however, that the patient gains his end more quickly by having definite practical seances. Again, attention may be drawn to the fact that joint anchyloses often arise after long and serious joint diseases (gonorrhoea, tuberculosis, purulent inflammation) or joint injuries, which for their primary treatment require long fixation, by which the mobility of the neighbouring joints suffers severely. In such a case after-treatment by medical gymnastics and massage is of course absolutely necessary.

Under certain conditions, however, such anchylosis may be the object of operative treatment aiming at the restoration of mobility in the anchylosed joint. This operation, known as arthreetomy, is seldom undertaken, since the result achieved is often a fresh anchylosis. As a rule it is only undertaken when the former anchylosis occurs in such an inconvenient position that a new anchylosis in a more suitable position allows the patient a considerably increased functional activity, and also only in those cases where the anchylosis has not been the result of a joint affection of such a nature that it has a tendency to light up again after operative interference. The result of arthreetomy is of course nil if gymnastic treatment is not given as soon as possible after operation for the mobilisation of the joint. On the other hand, it has often happened in recent years that mobility has been obtained in an anchylosed joint by such means, especially since the introduction of implantation of soft parts (fatty tissue, muscular tissue) between the operated free ends of bone. Where anchylosis, especially in certain joints, occasions great limitation of function, it is possible that such attempts to restore mobility will become more general.

Such after-treatment must not be looked upon as an unimportant part of orthopaedic surgery, but as of primary importance, for which the operation only prepares the way, and must be undertaken in the same way as any other joint mobilisation. As in all other severe joint affections, and especially after operation, the treatment must be given with the greatest caution. It is not by heroic manipulation one gains the end in view. Violent reaction of the damaged tissues to the strength of the manipulation quickly destroys the mobility which is the immediate effect of very strong massage. Very small movements, constantly combined with massage and other means of softening (warmth, rest, cold compresses, etc.), produce a more beneficial result than the violent breaking down of adhesions formerly employed, or the now abandoned redressement force. If by such mobilisation of a joint one can obtain a mobility which is considerably under the normal mobility of the joint, it is nevertheless a great gain to the patient. The difference between the functional power of an extremity with one joint completely anchylosed and the same extremity with the slightest mobility in the same joint is very striking. It is scarcely necessary to call attention to the necessity in an individual case of increasing mobility round the resting position which corresponds to the patient's most comfortable anchylosed position.

By joint contracture, according to von Mikulicz (German Congress of Orthopaedic Surgery, 1904), is meant "a partial or complete loss of either active or passive movement in a joint, excluding true anchylosis with firm union between the ends of the bones (by bone or connective tissue)." All stiff joints therefore come into this class, even a very partial, perhaps trifling, decrease of the normal mobility of a joint, or a complete stiffness approaching the limits of anchylosis. In all these cases of joint stiffness treatment by massage and medical gymnastics plays a prominent part. The important subject of physical treatment has already been discussed; I will therefore confine myself to the statement of a few special orthopaedic points.

The first question which interests us in the medical gymnastic treatment of stiff joints is, of course, when should a stiff joint be mobilised ? And the answer will be that every stiff joint should be mobilised if no definite contra-indication is present. The first contra-indication is a joint affection of any kind in the acute stage. It has been fully proved by experience, and is evident on reflection, that the final result of a joint treatment as regards function is best if one avoids increasing in any way the inflammatory reaction in the joint. This reaction is undoubtedly increased by too early and too violent movement, which unfortunately is often undertaken. Every diseased joint must therefore be given rest and fixation so long as it is painful on the slightest movement. Only when mobilisation without an anaesthetic gives no pain worth mentioning can such treatment be applied. Another contraindication is if anchylosis is the result of tubercular disease in a joint or its immediate neighbourhood. A joint whose limited mobility is due to a preceding tuberculosis has always been a noli me tangere for the medical gymnast; and this as a general rule unquestionably holds good. It must, however, be remembered that cases of tubercular disease of the joints often occur, perhaps most commonly in the hip joint, which are so slight and of such short duration that more or less mobility still remains after recovery. In such cases an experienced and careful doctor can without danger employ movement in order to increase mobility. It is often impossible to state definitely how soon the gymnastic treatment can be given without danger. The option must be left without reservation to the doctor who has followed the case throughout its entire course. It cannot be too much impressed upon gymnasts that all treatment of joint disease, acute or chronic, must be directed entirely by the doctor.

If the joint contracture is of such a nature that the joint has become fixed in a faulty position, the gymnastic treatment first aims at placing the joint in an advantageous position, i.e., correction. If an elbow is fixed in a too flexed position, the gymnast seeks to place it more or less at a right angle, which is the position of the joint in which an arm with a stiff elbow can best perform its functions. In the knee joint the position of extension is necessary for walking. It should here be stated that joint contracture, even without true anchylosis of the ends of the bone, may reach such a stage that mobilisation and correction are impossible by means of mechano-therapeutic treatment alone. The contracture may even be so severe that one can scarcely distinguish it from a true joint anchylosis. Without an anaesthetic, which is too often used in cases of differential diagnosis, it is generally possible by careful examination to state to what extent the disease is joint anchylosis or contracture. If one tries to move the joint, the muscles concerned actively resist if only contracture is present, but not if there is true anchylosis. Further, in extreme degrees of joint contracture one can clearly feel by means of fine oscillating movements in the joint that there is a slight amount of joint movement, which cannot be detected if large or violent movement is attempted. If any movement can be found it can often be greatly increased by the help of mechano-therapy; if, on the other hand, the joint is fixed in an extreme position, surgical treatment in the form of operation on tendons, muscles, or bone is often necessary as preparation for the equally necessary medical gymnastic treatment. The forced mobilisation which was often done under deep anaesthesia is now seldom applied, and is gradually going out of use. It was too often found that the most energetic gymnastic treatment in one form or another could not prevent the secondary shrinking of soft parts, due to the reaction of the tissues to this violence, so that the contracture remained as before. A good result can be achieved only when the patient possesses enough energy and self-control to undergo daily and long-continued treatment in spite of severe pain, which treatment must begin directly after the breaking down of adhesions, when the joint is still very tender. In such conditions one tries generally to attain one's end by gentle means, following the principle laid down for the proper treatment of joint contracture by the distinguished orthopaedist Gocht, that the correction shall be very gradual, done without anaesthesia and at the same time without pain, and for a period of several weeks. The correction of a severe joint contracture must be performed during separation of the articular surfaces as well as during mobilisation. All such treatment must be preceded and reinforced by massage, heat, baths, etc. All this makes it necessary for the treatment of severe joint contracture to be undertaken at institutes or homes equipped for the purpose. In all cases where there is a possibility of maintaining the mobility of a joint there is wide scope for medical gymnastics, since as a rule all stiff joints should be mobilised as far as possible, except the post-tubercular cases.

As to the technique of mechano-therapeutic mobilisation, it can undoubtedly in most cases be given manually, although it demands a great amount of energy and perseverance on the part of the gymnast. Since the treatment must be given with the greatest caution, the result is never very rapid; on the contrary, a long time is required. For the mobilisation of joints a system of medico-mechanical apparatus has recently been constructed and used. I would specially mention Krukenberg's pendulum apparatus, which are extremely useful in joint mobilisation. These apparatus, unlike the general medico-mechanical apparatus, are not very costly, and can therefore be used independently of the large orthopaedic institutes. Universal apparatus have also been constructed by the help of which most joint contractures can be treated by the same machine, which is fixed and arranged according to whatever movement is given. These apparatus do not lose patience, and work, therefore, a great deal better than any personal agent. Especially in the stage when the joint mobility is minimal these machines give a better result than gymnastics. Finally, it is the case here as elsewhere that a combination of all methods gives the best hope of progress.