With muscular contractures at the ankle the required right angle, or a certain amount of dorsal flexion, is often most easily attained by walking on sloping ground. Fixation in extreme positions can also be used in these cases when the patient has "worked up" his foot into performing maximum dorsal flexion.

With regard to contractures of nervous origin, I wish to remind my readers that both spastically contracted and weak and paralysed muscles ought to be massaged. Too much and too little activity alike cause disturbances in nutrition of muscles, and one may see contracted muscles after long hysterical contractures just as much atrophied as muscles strained by excessive exercise, or as weak or paralysed muscles may be after such a disease as infantile paralysis. In treating hypertrophied muscles no other manipulation is as suitable as effleurage, for this has the greatest effect on nutrition without being too stimulating.

It is specially in advanced cases of true joint contracture that beginners are doubtful as to whether to attempt forced correction. If by forced correction is understood breaking down a stiff joint by great violence, such an operation in my opinion ought never to be performed. If there are indications in favour of loosening a real anchylosis (a bony or fairly extensive fibrous union between the articular surfaces of a joint), this is better done nowadays by surgical operation than by such coarse and brutal violence as breaking down the joint. In the case of a pseudo-anchylosis or a contracture with minimum mobility it does not require great force, when the patient is under an anaesthetic, to stretch what can profitably be stretched, and to produce the amount of movement which can afterwards be restored by massage and gymnastics. By once performing these movements under an anaesthetic one gains important help towards the prognosis. Besides this, the performance of the most extensive movements possible, within the normal range of movement, while the patient is under anaesthesia which need not be deep, has great therapeutic value in that it interrupts the development of those changes which result from continued immobility, and considerably facilitates the future treatment by passive movements as far as the patient can endure them. The slight inflammatory reaction which follows such treatment by passive movements assists the absorption, which is one of the objects of massage. The performance without an anaesthetic of more extensive movements than the patient can endure without severe pain is wrong, and causes agony which may seriously affect the patient's nervous system.

Hippocrates in an unguarded moment once expressed the opinion that massage, which is able to make a stiff joint looser and more mobile, is also able to make loose joints firmer, and this little lapsus linguae of the venerable father has for centuries been repeated by mechano-therapeutic specialists, who have always been endowed with far more enthusiasm than critical faculty. "Loose joints" consist first of all of flail joints, which are most often due to an elongated fibrous union after a resection, or sometimes to strain of the capsule, with paralysis of the muscles, usually at the shoulder in paralysis of Deltoid. A flail joint requires chiefly orthopaedic apparatus to limit movement; massage and gymnastics can only strengthen the atrophied muscles. To shorten muscles which are too long by allowing them only to work in the "inner part of the range of movement" is at best a slow process. Our treatment is also rather limited in cases of stretched capsule. It can assist absorption of the exudation which caused the stretching, and to a certain extent can lead to greater tension in the capsule by strengthening the muscles. When the looseness of a joint is the result of torn ligaments, effleurage is specially useful in assisting rapid and good recovery, the latter also requiring in certain cases (e.g., lateral ligaments of the knee) fixation by some apparatus.

In massage of a joint only two manipulations are generally used, effleurage and friction. Occasionally with chronic sluggish processes, e.g., fluid in the joint, it may be well to make use of tapotement, for hard tapotement has a stimulating effect, produces congestion in the whole joint, and makes the processes more acute and so easier to bring to an end. When one wishes to produce more activity and increased local absorption in a joint after severe inflammation, and when hyperplasia remains, it is better to do this by local treatment with hot baths, either water, sand, mud or air, or by douches, than by tapotement on a joint, which is often very tender. We ought also to remember Bier's very useful bandage and the slight passive hyperaemia resulting from its use, though even now its effects are not universally known.

With regard to effleurage and frictions, it is easy for any one who understands their effects to assign to each its appropriate part in the treatment of a particular case. This merely involves the application of rules analogous to those already stated, perhaps too often, in other parts of the book. Effleurage is excellent when it is essentially a question of counteracting an acute inflammation, and is therefore of great value in acute serous synovitis and in simple traumatic joint affections. When these are quite fresh and in the most acute stage and all strong (mechanical) stimulation must be avoided, effleurage applied as light strokings, even over the inflamed part, is the only rational manipulation, and is as simple as it is effective. In these cases it should also not be forgotten that effleurage, when applied (as firm strokings) over the vessels in a central direction from (not over) the inflamed part, is able to help on the circulation and counteract stasis and inflammation in that part. Even in other cases effleurage should always, without exception, form part of the massage treatment of a joint in order to aid the circulation and thereby promote absorption and local nutrition.