I omit for want of space the resting positions and the common positions of contracture and mention here the desired positions (for contractures and anchylosis) of the remaining large joints. They are : almost complete extension at the knee, slight flexion, slight abduction and slight inward rotation at the hip, slight dorsal flexion at the wrist, flexion to a right angle combined with moderate supination at the elbow, slight flexion forward, slight abduction and slight inward rotation at the humero-scapular joint.

Any joint fixed in an abnormal position, however slight, should never be treated by massage and gymnastics alone. Such cases belong to orthopaedic surgery, and after forced correction or open operation should be fixed and left untouched for a short time, some days only, if there is hope of restoring any power of movement, and for a longer time, some weeks to two months, if there is no such hope and if anchylosis is desired. After the orthopaedic treatment massage and gymnastics are used in the former case to produce as much power of movement as possible in different directions from the desired position round the normal axis or axes of the joint, and to keep the nerves and muscles in a good state of nutrition.

From the patient's point of view the difference between the most favourable and a less favourable position of contracture or anchylosis and between an entirely lost or moderately limited power of movement is very great. The range of movement also is of great importance. A patient whose foot is fixed at right angles to the lower leg is much better off than one who is left to drag an anchylosed talipes equinus, and a patient who is left half the normal range of movement in the ankle suffers little inconvenience from his deprivation if he can move his foot equally in both directions from a position in which the foot is at right angles to the leg.

Different kinds of contracture call for very different kinds of treatment.

Dermatogenic contractures may arise as the result of large burns of the third degree, which cause widespread radiating scars in the true skin and subcutaneous tissue, more or less deep, and tending to contract by degrees. If the whole of the injured part is treated, preferably as soon after healing as possible, with small but firm frictions, after much hard work sufficient softening without actual breaking down of the scar tissue can be produced to considerably facilitate the performance of passive and active movements, and even to restore a certain amount of mobility.

With regard to the contractures which arise from chronic inflam mation and shrinking of the fascia, it is better to point out the extreme difficulty of gaining any satisfactory results by means of massage and gymnastics than to make any rash promises of cure. Billroth's assistant, Barbieri, an excellent masseur, was the first, to my knowledge, to show that good results can be obtained by this method in the treatment of Dupuytren's contraction. But an enormous amount of work consisting of firm frictions and passive movements of the fingers is necessary to obtain these results. It is better to entrust the first treatment of this complaint to the surgeon and only to employ the other methods in the after-treatment.

If a contracture is due to atrophic shortening of muscles, massage cannot restore the normal condition even at an early stage of the case, and I am inclined to give a similar verdict in the case of gymnastics. One can certainly tear and so stretch shortened muscles, and hasten their recovery by means of effleurage, but this method would be difficult to apply to any but fairly small muscles.* The best form of gymnastics to lengthen shortened muscles is, without doubt, eccentric movements in the outermost part of the range of movement while the patient gives strong resistance, but even with this method the results are very slow.

* Some years ago I had an opportunity of showing a case of this kind to some of my colleagues in Stockholm. The patient was an American lady, and is very well known in certain Boston circles. Serious loss of functional power in all four extremities had resulted from too long fixation after extensive injuries in a railway accident. The extensive traumatic myositis in the legs was soon cured, and the power of walking was restored without much difficulty. The fingers of both hands were held in the position of athetosis and could not be bent on account of the shortening of the extensor muscles. I stretched the extensors by means of strong, but at the same time slow, passive movements, and in a comparatively short time removed the swelling and pain from the forearm by effleurage. functional power was completely restored. The marked limitation of supination of the right forearm was got rid of by a forcible supination, which apparently tore Pronator Quadratus from its attachment to the radius. But here, too, everything went on satisfactorily, although the arm could never be quite fully supinated.

The method of tenotomy lengthens by inserting scar tissue into the tendon in place of the voluntarily contractile muscular tissue, but this is unsatisfactory. The alternative is combined orthopaedic, massage, and gymnastic treatment, which is most easily applied if the contracture in question affects the knee or elbow. If, for example, we have to treat a case of contracture of the elbow, in which extension can only be performed to a right angle, we place the joint in this position in plaster of Paris and leave it for about a week. When the plaster is taken off we find that the shortened muscles have been lengthened by their own "tone," as it were, and that extension can be performed a few degrees further than before. We then proceed to treat the arm with massage and passive and active eccentric gymnastics for about fourteen days. After this we again place the arm, extended as far as possible, in plaster of Paris and continue the treatment of alternate fixation and massage and gymnastics until our aim is at length accomplished. Fixation in extreme positions is painful and involves the use of some soothing drug.