After Sprains or Wrenches, i.e., after violent, generally passive movements which, though beyond the normal limits, have stopped before causing a dislocation, we find the joint acutely inflamed and the ligaments strained and possibly torn (and extravasation of blood). In these cases massage has very much lessened the prolonged application of firm bandages, which were formerly used. It has also even improved the prognosis, which was already good, hastened complete recovery, and lessened the number of those cases in which a sprain, like other traumata, gives rise to lengthy and more serious troubles. The value of effleurage as an antiphlogistic and in aiding nutrition is well shown in those cases where effleurage is begun immediately after the trauma and continued until recovery is complete. Even when parts have been torn, Swedish doctors do not generally use tight bandages; in fact these bandages have fallen almost entirely into disuse in the case of the ankle joint. But when one of the lateral ligaments of the knee is torn or detached from the epicondyle of the femur or tibia the joint must be absolutely fixed for fourteen days, to help it to heal in the proper position and to prevent abnormal side movement and an abnormal position later on. Normal movement can be restored afterwards by means of massage and gymnastics. In the case of those sprains, with or without tearing of the parts, in which we avoid tight bandages we always order rest and employ massage without movements for the first few days after the trauma.

From time immemorial (Hippocrates) it has been the custom to stroke and rub a dislocated joint after its reduction. By Dislocation is meant that the articulating surfaces of a joint are partly or entirely removed from one another by excessive movement or by some other force. If large vessels are torn, which is a rare complication, massage, just as in the case of fracture, should be postponed. But this is not the case if the nerves have been stretched or bruised; nor do bruised or strained muscles contra-indicate massage, but on the contrary are cured by it.

Treatment by effleurage and frictions may thus be given in most cases immediately after reduction. It is usual to wait until the most violent symptoms are over before giving movements. I may, however, remark here that a Swedish doctor well versed in mechanotherapy seldom waits more than eight, never more than fourteen. days after simple dislocations, of which the commonest are those of the shoulder, before he begins careful passive movements, as soon as possible performing these through the whole normal range of movement.

After unreduced or irreducible dislocations massage and gymnastics are often of very great use in procuring no small degree of movement in the pseudo-joint, or rather new joint, formed between the dislocated head and the surrounding tissues.

Fracture in or near a joint is in most cases an indication for massage, in all cases for gymnastics, but only after union has taken place, which is produced by fixation and complete exclusion of all movement, but is striven after in many different ways. At this point I wish to call the reader's attention to the importance of thoroughly understanding the difference between fixed apparatus on the one hand and massage and gymnastics on the other. Splints or fixed apparatus certainly assure union in a normal position, but they have an unfavourable effect on circulation and nutrition, causing stasis with passive inflammation, and, what is worse, various kinds of atrophy, especially that tiresome kind known as atrophic shortening. Surgeons have, quite naturally, generally thought more of the importance of union in the right position than of the future power of movement, and have erred in using too heavy apparatus and in using it too long. But, on the other hand, masseurs and gymnasts, with or without medical training, have often put themselves in the wrong and caused tiresome complications through their keenness to try their treatment, and through their one-sided views as to its proper place and the disadvantages of fixed apparatus. At the present day, besides doing away with all methods which do not result in complete union and a good position, there has been a tendency as a whole only to make use of fixed apparatus so long as it is essential, to make the apparatus easier of application by exchanging heavy plaster of Paris for splints, or by converting the plaster of Paris case into a capsule by cutting it along both sides. This capsule, like other lighter apparatus, can be removed during massage and then replaced. This modern treatment, which in the case of intra-articular fractures often includes suture of the fragments, is known to hasten the union of the fractured parts. Nowadays intra-articular fractures are seldom fixed and left undisturbed for more than eight, never for more than fourteen, days. As soon as this time has elapsed massage is begun, and soon after gymnastics, to counteract and efface the harmful effects of the apparatus. Just as bandages prevent, so effleurage hastens the flow of blood and lymph in the part to which it is applied, and also improves the already lowered local nutrition. Both effleurage and frictions help the absorption of the products of stasis, and of the more or less plastic infiltrations. Passive and active movements entirely prevent the harmful results of immobilisation, already frequently mentioned, on joints and muscles.

After the healing of penetrating wounds of a joint the aim of the masseur varies between breaking up by means of effleurage and frictions the slight infiltrations left in the capsule and surrounding tissues by a non-infective trauma, and restoring as far as possible the use of a joint after purulent synovitis, which has not caused anchylosis and utter uselessness of the joint, but has at least seriously injured it. In the same way that modern antiseptic treatment has to a great extent, increased the probability of saving joints from complete destruction when penetrating wounds or some other cause have made them purulent, a rational use of mechano-therapy has increased the chances of regaining the power of movement in a joint even in severe cases. There is an infinite difference in the prognosis given now and that which would have been given about 1850 with regard to a patient with a penetrating wound of the knee joint.