The Knee Joint provides the masseur with an enormous amount of work.

Among the non-traumatic affections tuberculosis is very common, and as long as it is present as such is a noli me tangere for the masseur. When there is hope of restoring mobility after other metastatic inflammations of the knee it means very hard work for the masseur.

The chronic serous synovitis with copious exudation, hydrarthrosis or fluid in the joint, is a common and rather obstinate affection which has already been referred to.

The extraordinary, rather rare, affection known as intermittent synovitis has been treated by massage, sometimes with and sometimes without success. I have had experience of both. Intermittent hydrarthrosis is not a very suitable name, since the attacks which occur at varying intervals, generally of over a week, usually accompanied by symptoms of the nature of migraine, are characterised rather by considerable swelling of the capsule and the neighbouring periarticular tissues, especially above and at the sides of the patella, than by effusion in to the joint cavity. The affection is probably partly a vasomotor neurosis, and it is very uncertain whether treatment by massage is of any use. In, however, one case the symptoms in the neighbourhood of the joint were gradually reduced to a minimum during massage treatment, whereas the other symptoms (headache, sickness, and nausea) remained as before.

By no means such a thankless task is the treatment of the "circumscribed capsulitis" already referred to, a serofibrinous infiltration in the wall of the capsule without any exudation into the joint cavity. It is an affection which the masseur should always bear in mind. Though on examination the only sign may be a scarcely visible and scarcely palpable thickening on either side of the ligamentum patellae or patella and a few frictions applied at the right spot are able to effect a cure, yet it may force the patient to use crutches for years and make him practically a cripple. Even when the patient has experienced such discomfort from capsulitis, he has generally used his muscles sufficiently to prevent the tiresome contractions due to their shortening, and when the infiltrations are removed recovery is practically complete. Some of the wonders most talked about which are wrought by massage are those having to do with the treatment of circumscribed capsulitis.

Synovitis crepitans has also been already referred to. Even if it cannot be completely cured, there are cases which profit considerably in which considerable mobility can be restored and maintained, though only by an enormous amount of work with frictions on the capsule and surrounding parts (the treatment being repeated for a few weeks every year). This also applies to those cases in which the mobility of both knees has been reduced to a few degrees, provided that the patient's general health is fairly good and that the changes occurring in old age are not too far advanced.

Of joint injuries the only ones of sufficiently common occurrence to be worthy of mention are sprains of the knee, dislocation of the patella, and dislocation of one of the semilunar cartilages.

Of these it is only sprains which can be said to be of common occurrence. These are combined with strain of the internal or external lateral liagment. In such cases one can feel a more or less distinct swelling on the inner or outer side of the joint, and on palpation the patient is aware of tenderness. There may be a very tiny exudation into the joint cavity, but this is generally absent. If the case comes under proper massage treatment immediately after the trauma, recovery is generally complete in quite a short time.

If either of the lateral ligaments is badly torn or detached from its insertion on the epicondyles of the femur or tibia, so that abnormal lateral movement can be performed, it is the custom in Sweden to fix the joint for about fourteen days to insure healing and a normal position later on. This is opposed to our usual treatment in dealing with sprained ankles. After this fortnight's fixation, massage and gymnastics easily restore complete mobility.

Among the various forms of dislocation of the patella, displacement due to some strong force from without is the most common (even if we except habitual dislocation, which is fairly common, especially with genu valgum). In this case the patella sometimes rotates on its vertical axis, so that its inner edge, or even the whole of its inner surface, is directed forward, the outer edge resting on the external condyle of the femur. In such dislocations Vastus Internus is always severely strained and somewhat torn from its insertion, and the capsule is often considerably torn.

Massage after reduction is a great help towards restoring normal conditions.

The masseur sometimes meets with cases of dislocation of the semi-lunar cartilages. The pathological anatomy of these affections is well known now that innumerable cases have been operated upon.* Dislocation of the inner meniscus is the more usual, and is combined with more or less extensive tearing and breaking of its insertion. The displacement may be inward towards the joint or outward; in the former case a depression, in the latter a bulging, can be seen at the articulation. Dislocation is probably brought about by a violent rotation of the tibia combined with a certain amount of flexion, outward rotation causing dislocation of the inner, inward rotation causing dislocation of the outer meniscus. After the dislocation the patient suffers continual pain, keeps the leg somewhat flexed at the knee, can flex it further, but cannot extend it. The diagnosis of this affection as distinguished from a foreign body is made from the history and by palpation, in which the dislocated cartilage is felt to be fixed and the symptoms are localised to its area. A foreign body, on the other hand, may easily be moved and appears in different parts of the joint, and the pain and tenderness vary in position accordingly, but are lessened or increased by movements.