As soon as it is a question of promoting retrogressive changes, the breaking up, and, finally, the absorption of the pathological tissue elements, frictions are the most useful manipulation. When one has to deal with fresh, to some extent organised, masses of connective tissue with the accompanying newly-formed capillaries, deep frictions are applied (generally with the thumbs), whether these capillaries have been formed owing to the inflammatory affection of the joint or owing to the passive inflammation caused by bandages. In these cases, and whenever a strong mechanical stimulation is not dangerous, we apply effleurage more firmly, preferably at the beginning and end of each seance.

There are various other general rules with regard to technique which I should like to recapitulate.

It is always best to begin the seance with effleurage over the vessels, beginning just below the joint and continuing some distance above it. Only in cases when tapotement seems necessary is a seance begun with this manipulation.

Frictions ought always to begin in that part of the affected tissues lying nearest the centre (of the circulatory system), because what is broken down can be pressed into the lymphatics more easily and with less pain than in the peripheral parts of these tissues, where the tension and resistance in the smaller lymphatics is greater.

Passive movements are performed towards the end of the seance, and are usually followed by effleurage, which removes the resulting irritation and pain and always makes a satisfactory ending.

When the patient is allowed to use local hot baths or douches or Bier's bandage, it is best to massage immediately afterwards, while the tissues are hyperaemic, absorption more active, and the tenderness less than usual.

When atrophy of the muscles or any such tendency is present, which is always the case when a joint has been much limited in its movements for any considerable time, one should never neglect to massage these muscles very thoroughly.

Gymnastic treatment is an important accessory to the treatment of many joint affections which require massage, but should not be used side by side with massage under all conditions. Movements are injurious during the most acute stages of an inflammation in a joint, because they increase the flow of blood to the joint (as to any organ which is brought into activity) and so encourage the inflammation. The beneficial effect of movements in helping the circulation can never counterbalance the above harmful effects, but this can, especially in some joints, be compensated for by effleurage. May I say as a reminder to many of my countrymen who want to use gymnastic treatment in season and out of season that immediately after sprains, contusions, reduction of dislocations and after fractures, and with acute synovitis of all kinds, rest is indicated and any movement contra-indicated. As the symptoms of inflammation begin to disappear the patient may be allowed to begin using the joint and to use it gradually more and more. This usually takes place in a few days, at the most fourteen days, after any trauma not involving fracture, and so before the rest has had time to cause any serious disturbance.

In treating severe affections of joints one's object, viz., to restore to the patient a fairly useful joint, is only attained little by little by daily energetic treatment week after week, or perhaps month after month, and one must not lose hope if at first this seems difficult or even impossible. In some cases one finds hardly any visible power of movement in the joint, the external form is effaced by masses of new connective tissue or by hard cellular oedema with marked plastic tendency, the capsule (as far as can be ascertained by palpation) is extremely infiltrated and much thickened, the muscles atrophied and, worst of all, perhaps more or less shortened, and a great part of the extremity often colder than normal owing to the bad circulation. The aim and method of treatment in such cases are to remove the inflammatory products from all the tissues (especially the capsular and pericapsular) and help on the circulation by applying deep frictions and effleurage; to prevent atrophy of the muscles by using every kind of manipulation as well as orthopaedic treatment, which is the best means of stretching muscles as well as other soft parts when contracted; gradually to increase the mobility of the joint, stretch or tear adhesions which have been formed, and set free the tendons which have become firmly attached to their sheaths by means of passive movements given by suitable contrivances (i.e., as far as this can be done without lowering the patient's strength by excessive pain and without causing a new inflammation, and just so far as massage is able to restore the tissues to a normal condition); to make use of systematic active movements as soon as sufficient mobility has been attained; at the same time to make use of various local baths, douches, Bier's treatment for stasis, injections of fibrolysin, etc.; lastly, to remember to treat the general condition if this is in need of it. All this forms one of the most delightful and interesting problems for the doctor-masseur, and its satisfactory solution requires no little knowledge and experience, and still more tact, energy, and perseverance. The results, however, are often far better than could ever have been expected by those who have not experienced what a thorough rational meccano-therapeutic treatment can effect.

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