Stage 4: Increase of Internal Massage. - After the usual preliminary smooth massage the bandage fixing the ankle is removed, leaving the limb secured above by the bandage at the knee, and at the seat of fracture by the grasp of one hand of the manipulator. The other hand insinuated between the sole and the foot-piece of the splint firmly but gently grasps the foot and makes passive flexion at the ankle as freely as possible five or six times without moving the fractured bones. The date of commencement of this stage may be any time after the fourth day, but may in difficult cases have to be postponed as late as the eighth or even the tenth day. The object is movement of the ankle-joint and muscles at the back of the leg and the calf to prevent adhesions, especially at the posterior aspect of the fracture. At the end of this stage the splints are replaced as in fig. 1.

Such is the way in which massage and early movements may be used in any ordinary case of fracture of the leg. The nearer the fracture is to a joint the more important it is that this method should be carried out, for the simple reason that the nearer the fracture is to a joint the more likely is it that there will be subsequent pain and stiffness.

Please understand that the use of massage and passive movement in these cases in no respect lessens the necessity for the point of primary importance in all fractures-i.e. placing the fragments at the outset in accurate position.

Pott's fracture is always a difficult fracture, as is well known, not only on account of the difficulty which often arises in the 'setting' of it, but because of the matting of parts which is liable to take place afterwards. Once the bones are in good position in this fracture you need have no hesitation in beginning passive movement in two or three days after the injury at the latest, and smooth massage may be commenced directly after the accident with great advantage. Because Pott's fracture happens to so nearly involve the ankle-joint there is no reason why passive movement should not be used immediately; on the contrary, this is a strong reason for its adoption, for it is only by its use that the avoidance of adhesion and stiffness can be with certainty accomplished (vide fig. 7). I have described the case of a fracture of the leg because it is one of the most easy of fractures to manage by this method. When fractures are treated on the lines I have described it will be found, if the practitioner will devote the necessary time, and when the sufferer has the patience, that a better result will follow than can be effected by any other plan without operation, and that ultimately the time which is occupied in the complete recovery of the patient is little more than half of that which follows the treatment by splints in the ordinary manner.