Gouty Arthritis is not one of those joint affections for which massage is of great curative value. There is no hope that massage can have any effect on the deposits of uric acid and urates which are to be felt in advanced cases. Massage is equally out of the question when open ulcers are present, and even apart from this it may be harmful through injuring the frequently sclerotic vessels. On the other hand, it is probable that massage, if used from the very beginning in a case of this sort, can to a certain extent prevent the development of articular changes. Lastly, I have great reason to believe that the typical attacks can be much alleviated by effleurage, and that massaging a joint may keep it free from attacks for a time. The late Dr. Fogman told me that in six cases of gout he had been able to ease his patients' pain so much by giving effleurage, at first lightly, later more firmly, that though during previous attacks they had been forced to go to bed, they were then able to be up and to move about more or less easily. I was once, with very little hope of good result, almost forced by a gouty German colleague to massage his gouty knees. I do not think there was any doubt about the affection being gout. A boil, which had developed before treatment began, prevented massage over one knee. The difference between the massaged and the unmassaged joint during the next year was, contrary to previous experience, remarkable, and the patient himself entertained no doubts as to the therapeutic value of the treatment.

In certain diseases of the Central Nervous System, especially in tabes dorsalis, the joints are often affected to a very serious extent. In tabes it is generally the joints of the lower extremities that are concerned. Many people consider that the changes which take place depend partly on peripheral neuritis and disturbed trophic influences, partly on the too extensive movements and other purely mechanical consequences of ataxy and analgesia combined. It would never occur even to the most undiscriminating advocate of mechano-therapy to attempt to treat the apology for a joint resulting from advanced tabes by massage and gymnastics. In such a joint the movements are abnormally free, the ligaments stretched and partially torn, extreme hyperplasia is present, hypertrophic and atrophic changes exist side by side, there is a large, often purulent, exudation in the joint cavity, and changes in the bony parts which sometimes affect the whole of the epiphyses. The task of the orthopaedist is to see what can be done to alleviate the distress of a patient in this condition. All that can be said in favour of massage is that it may have some prophylactic influence and prevent the above-mentioned changes, or perhaps retard their development in the first stages. I shall return to the subject of gymnastics and massage in the treatment of tabes when I deal with Frenkel's treatment later on.