In fracture of both tibia and fibula the treatment with plaster of Paris is the same, but lasts about twice as long. After two or at most three weeks the plaster, which has been converted into a capsule, is removed daily so that effleurage and graduated gentle passive movements may be given. It often takes a long time to remove the products of the active and passive inflammation in the tibio-tarsal joint and round the tendo Achilles by means of hard frictions and effleurage. The use of the joint, especially walking on slopes of varying steepness, is the best form of gymnastics at the end of the treatment.

In effusion in the ankle joint an elliptical protuberance appears on either side of the extensors. With metastatic inflammation in this joint the neighbouring joints also easily become inflamed. If the joint has not been kept in a right-angled position (by means of von Volkmann's splints) the atrophic contraction is generally greater in the peronei than in the calf muscles and the foot assumes the equino-valgus position. The best gymnastic treatment for producing the valuable right angle between the foot and lower leg is, if anchylosis has not developed, to allow the patient to walk up gentle slopes as soon as possible after healing.

Chronic progressive polyarthritis, secondary rheumatic inflammation, and arthritis deformans are not specially uncommon at the ankle and both the lower talo-calcaneal joints.

In giving massage and gymnastics of the foot it is most convenient to have the patient in half-lying position on a plinth. In giving plantar and dorsal flexion, among the passive movements the masseur must be careful when grasping not to press unnecessarily hard on the ball of the toes, which is often tender. The grasp for this movement is obvious. If necessary, one must not omit passive inversion and eversion, grasping the lower leg above the malleoli with one hand, with the base of the other hand pressed against the foot below the external and internal malleoli.

It is of the greatest importance that doctors when treating joints by massage and gymnastics, as with other forms of treatment, should not confine themselves to this treatment alone. This fault is constantly being committed by some who have made a speciality of this treatment, with the result that they are in fact ignorant of all else. I therefore take the liberty of reminding my readers "as delicately as possible" that, especially in joint affections and apart from surgical treatment, we have a great many other methods which are not at all to be despised.* Many of these aim at producing local changes in the circulation, especially passive or active hyperaemia.

* I have excluded various treatments of subordinate importance, among them, first and foremost, the now generally abandoned blood-letting, as well as cauterisation, blister, plaster, and ointment of all kinds. Mercurial ointment, which in other respects has been of such enormous service to mankind, I exclude here, as it is somewhat less generally used now, except in the treatment of syphilitic affections of the joints. Troublesome and unpleasant cataplasms have been superseded by warm water compresses, or by local baths of hot water, sand, light, air or mud, which are better in all respects The everlasting tincture of iodine, so highly thought of by many, has its value, but ought not to be used at the same time as massage, because it makes the skin unfit for this much more efficacious treatment. The fact that some authors recommend electricity applied directly to the joint makes it easier for me to confess that I too have tried it at one time in such cases, where, according to my opinion, whether as galvanic or faradic current, it is a mere farce. Its value in the treatment of the muscular paresis which often follows cannot be questioned, but even here mechano-therapy gives such obviously better results that one who is well acquainted with it is tempted to ignore electricity.