We know that physical exercise is necessary to develop and maintain the normal size, firmness, and shape of the bones, and that in this respect gymnastics has a prophylactic and hygienic value. We have also seen the therapeutic importance of gymnastics in connection with changes in the bones and ligaments. At first sight movable pressure on the soft parts does not seem likely to exert any influence on affections of bone, hut, where anatomical conditions favour its use, effleurage has a definite and valuable effect on the healing of bone after injury by improving the local circulation and nutrition.

Gerst has shown that after violent contusions of the leg resulting in necrosis and absorption of bone substance in the tibia, healing and repair take place with astonishing rapidity when effleurage is used over the limb.

Effleurage of the front of the neck has also been shown by Gerst to have a similar influence in severe blows on the head with concussion of the brain, intracranial haemorrhage, and probably in fracture of the base of the skull.

I pointed out (in the eighties) that in the absence of callus formation, and when pseudarthrosis has formed after fracture, effleurage has the power of producing bony union in a comparatively short time even when all the usual methods have failed owing to bad general nutrition. The case then quoted was that of a dressmaker, aged forty-two, who had been delicate all her life, and who broke both bones of the right forearm in the middle. The arm was first kept in plaster of Paris for six weeks, and was then operated upon by Professor Berg, who sutured the ends of the bones, but ten weeks after the operation no trace of callus appeared. By means of effleurage, at first twice, later once, a day, taking care not to allow the least rubbing of the bony ends against each other - this rubbing had been tried most energetically with a view to producing callus before effleurage was begun - callus formation began within a short time, so that bony union was complete after six weeks' effleurage, during which time all other treatment was withheld. I consider this case a clear and convincing experiment. I have since been able many times to observe the great influence of effleurage on callus formation, as well as on healing processes in general, in those parts which are most suitable anatomically for this manipulation, i.e., in the extremities.

*****

Though massage was used in the olden days in the treatment of joint affections, it was in the middle of the nineteenth century, through the influence of the French surgeon Bonnet, that this treatment became general. Gymnastics, especially in the form of passive movements, has always formed part of the treatment of such cases.

At the present day a treatise on joint affections is difficult, chiefly owing to our ignorance of their aetiology, and to a great extent to the faulty use of the rather vague term rheumatism. By adopting the classification of Hildebrand in his manual (1905), with a few alterations mainly in accordance with Payr, I hope to give a fairly good survey of the whole subject.

Traumatic * Joint Affections.

A. Contusions.

B. Sprains.

C. Dislocations.

D. Fractures.

E. Penetrating ulcers.

Non-Traumatic Joint Affections.