SPRAINS AND ALLIED 
 INJURIES OF JOINTS 
 
 R.H.ANGLIN WHITELOCKE 
 
LIBRARY 
 
 University of California. 
 
 Class 
 
 Mmm 
 mmml 
 
 mmm 
 
 
 
 
OXFOBD MEDICAL PUBLICATIONS 
 
 SPRAINS AND ALLIED INJURIES 
 OF JOINTS 
 
OXFOBD : HORACE HART 
 PRINTER TO THE UNIVERSITY 
 
OXFORD MEDICAL PUBLICATIONS 
 
 SPRAINS AND ALLIED 
 INJURIES OF JOINTS 
 
 BY 
 
 R. H. ANGLIN WHITELOCKE 
 
 M.D., M.C. (Edin.), F.R.C.S. (Eng.) 
 
 HONORARY SURGEON TO THE RADCLIFEE INFIRMARY AND COUNTY 
 
 HOSPITAL AT OXFORD ; LICHFIELD LECTURER IN SURGERY 
 
 IN THE UNIVERSITY 
 
 Of THE 
 
 UNIVERSITY 
 
 OF 
 
 LONDON 
 HENRY FROWDE HODDER & STOUGHTON 
 
 Oxford University Press Warwick Square, E.G. 
 
 1909 
 

 BIOLOGY 
 
 «5te 
 
 «H 
 
Of THE 
 
 UNIVERSITY 
 
 OF 
 
 PREFACE 
 
 Three events in recent times have suggested the 
 writing of this volume, and seem to justify its 
 existence. 
 
 The more extensive employment of radiography 
 by surgeons as an aid to diagnosis has led to the 
 discovery that a great many injuries which formerly 
 were believed to be simple sprains, and treated as 
 simple sprains, are in reality injuries to bones, and 
 therefore of more serious consequence. 
 
 The passing of the new Workmen's Compensation 
 Act and its operations have not only drawn the 
 attention of the lay public to these accidents, but 
 have placed them on a much more important footing 
 in the estimation of the members of the profession 
 than formerly. 
 
 It is incumbent upon every practitioner that he 
 should not only be able to treat these affections 
 successfully, but that he should also be able to give 
 a sound and reliable prognosis concerning them. 
 
 Every succeeding day brings the medico-legal 
 aspect of the subject into greater prominence, for 
 not only is the question of compensation an impor- 
 tant one with Insurance Companies, but it is found 
 that it is in this particular class of slight or minor 
 
 204140 
 
vi PREFACE 
 
 injuries that the greatest difficulty is experienced 
 in estimating the exact monetary value of a claim. 
 
 At the present time not only do the uneducated 
 and those of the lower orders of society seek the 
 advice of unqualified practitioners only too fre- 
 quently, but it has become the fashion for the 
 ' smart set ' to flock in increasing numbers to the 
 waiting-rooms of those who proclaim loudest their 
 skill, and who perhaps pay most for their daily 
 advertisements. 
 
 It is not claimed for the present treatise that it 
 represents all that is known on the subject, but 
 rather that it supplies certain details, operative and 
 otherwise, which are not to be found in the ordinary 
 textbooks on Surgery. 
 
 It is the embodiment for the most part of the 
 writer's own personal experience, and as such may 
 be helpful to some who may not have had his almost 
 unique opportunities for dealing with athletic and 
 other injuries. 
 
 As in the text certain terms, as ' wobbly- joint ', 
 ' weak-joint', ' drop-top ', ' mallet-finger', have been 
 introduced, some explanation seems necessary. It 
 was found almost impossible to do without them, for 
 to the lay mind they convey a definite and specific 
 meaning, and are expressions presumably intro- 
 duced by and remaining in the daily use of bone- 
 setters and others. 
 
 It is to be regretted also that the expressions 
 
PREFACE vii 
 
 ' rider' s-sprain ', ' tennis-leg ', and many others similar, 
 should have crept into surgical literature. 
 
 Certain repetitions, especially in relation to ana- 
 tomical points, are to be found ; they are made with 
 a view to the accentuation of important facts. 
 
 Mr. W. Elliot Stanford, of New College, kindly 
 wrote the details of the accident to his wrist, entail- 
 ing a fracture of the scaphoid bone. 
 
 All the illustrations, excepting Fig. 45, the block 
 for which was lent by Messrs. Lindsey and Sons, 
 surgical instrument makers at London and Oxford, 
 are original, and were taken, with few exceptions, 
 from the author's own cases. 
 
 The radiograms, with the single exception of 
 Fig. 18, kindly lent by Mr. Edwin Dening, together 
 with most of the photographs, were taken for me by 
 my friend and colleague, Mr. R. H. Sankey, M.A., 
 M.B., B.Ch., Oxon., Honorary Radiographer to the 
 Radcliffe Infirmary and County Hospital at Oxford. 
 
 Only four drawings appear in the work, those with 
 the photographs of the specimens of semilunar 
 cartilages were made by Mr. A. Robinson of the 
 Oxford Museum. 
 
 The temperature charts are all the work of Miss 
 Agnes Still. 
 
 I wish to take this opportunity of expressing to 
 each of those who have so kindly and ably contri- 
 buted to the illustrations, my best thanks for the 
 trouble and skill they have bestowed, and to acknow- 
 
viii PREFACE 
 
 ledge my thorough appreciation and indebtedness 
 to those of my undergraduate friends who have 
 kindly allowed themselves to be photographed. 
 
 I wish also to place on record my indebtedness 
 to those members of the profession who from time 
 to time have written on these and kindred subjects, 
 and especially to Sir William Bennett, Professor 
 Howard Marsh, and Mr. L. B. Rawling, to each of 
 whom I have made reference in the text. To my 
 friends at 35 Harley Street, Drs. G. C. Cathcart and 
 Theodore Thompson, for reading the proofs, and to 
 the authors of that excellent textbook on Surgery, 
 Messrs. Thomson and Miles, whose arrangement of 
 surgical anatomy I have in a measure adopted, my 
 best thanks are here offered. 
 
 St. Giles' Gate, Oxford 
 February, 1909. 
 
CONTENTS 
 
 CHAPTER I 
 
 PAGE 
 
 Introductory 1 
 
 Concerning the Structure and Function of Joints. 
 
 CHAPTER II 
 
 Sprains considered generally 
 
 Introduction — Definition — Classification — Articular Sprains 
 — Muscular Sprains — Simple Sprain — Strain — Complicated 
 Sprain — Sprain-fracture — Sprain with fracture — Sprain- 
 dislocation — Sprain with gross nerve lesion — Hsematomata 
 Diagnosis — Prognosis — Treatment — of Strains — of Sprains 
 with immediate swelling — Elastic Pressure — Method of 
 AppHcation — Special advantages — Active Voluntary Move- 
 ments — Passive Movements — Constitutional Complica- 
 tions — Tension in joints after sprains — Arthrotomy and 
 digital exploration — Sprain complicated with injury to the 
 nerves — Sprains with fractures. 
 
 CHAPTER III 
 
 Sequels of Sprains 41 
 
 Preventable sequelce — Stiff and painful joints — Atrophy and 
 wasting of muscles acting on joints — Recurring or relapsing 
 synovitis — A relaxed condition of joints known as ' wobbly 
 joint ' or ' weak joint ' — Persistent pain in a joint — 
 Crippled or deformed joint — Improperly united muscles 
 and tendons — Ankylosis. 
 
 Unavoidable sequelce — Localized paresis or paralysis — 
 Ossifying myositis — Osteo-arthritis — Loose Bodies. 
 
X CONTENTS 
 
 CHAPTER IV 
 
 PAGE 
 
 Individual Articular Sprains . . . . . .74 
 
 Of the Upper Extremity — Sterno- clavicular joint — Acromio- 
 clavicular — Shoulder — Elbow — ' Dislocation by elonga- 
 tion ' — Wrist — Fracture of Scaphoid bone — Sprain of the 
 thumb — ' Drop-top ' or ' mallet finger ' — Sprains of the 
 finger-joints. 
 
 Of the Lower Extremity — Hip-joint — Ankle-joint — ' Meta- 
 tarsal pain ' — Tarso-metatarsal joint. 
 Sprains of the Body — of the side (intercostal muscles) — 
 sacro-coccygeal sprain — coccygodinia. 
 
 CHAPTEil V 
 
 Sprains in the Eegion of the Knee-joint .... 109 
 Surgical anatomy — Sprains of the knee considered generally 
 — Traumatic Hydrops — Sprains in which the internal 
 lateral ligament is most concerned — Sprains in which the 
 external lateral ligaments are most concerned — Separation 
 of the body of the internal semilunar cartilage from the 
 deep fibres of the internal lateral ligament. 
 
 CHAPTER VI 
 
 Internal Derangements of the Knee-joint . . .124 
 Displaced, detached, or torn internal semilunar cartilage — 
 Anatomy — Symptoms and clinical characteristics — Diag- 
 nosis — Causation — Treatment of first attack (immediate 
 and subsequent) ; of recurrent or relapsing cases — Pal- 
 liative treatment — Operative treatment — Essential pre- 
 liminaries to operations — Displaced external semilunar 
 cartilage — Hypertrophied synovial fringes. 
 
 CHAPTER VII 
 
 General Injuries to Muscles and Tendons . . .169 
 Muscle sprain — Hernia of muscle — Displacement or dis- 
 location of tendons — Rupture of muscle or tendon. 
 
CONTENTS xi 
 
 CHAPTER VIII 
 
 PAGE 
 
 Individual Injuries to Muscles and Tendons . . .187 
 
 Ruptures of muscles and tendons — 
 
 Muscles of the Trunk — Rectus abdominis — Oblique 
 muscles of the abdomen — Ilio-psoas muscle — Sacro- 
 lumbalis. 
 
 Of the Upper Extremity — Deltoid, ' cricket shoulder ' — 
 Biceps cubiti — Triceps — Muscles of forearm. 
 
 Of the Lower Extremity — Rectus femoris — Quadriceps exten- 
 sor — Hamstrings — Adductor longus — Brevis and pectineus 
 — Adductor magnus — Ligamentum patellae — Muscles of 
 the calf, ' lawn-tennis leg ' — Tendo-AchilUs. 
 
 CHAPTER IX 
 
 Massage, Movement, and Exercises in the Treatment of 
 
 Sprains and Bruises 210 
 
 Massage — Passive movements — Active voluntary move- 
 ments — Forcible movements of stiff joints under an 
 anaesthetic — Means adopted for preventing muscle waste 
 by active exercises — Movements and exercises against 
 resistance — by means of weights and pulleys. 
 
 APPENDIX 222 
 
 INDEX 229 
 
LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 1. Fracture -sprain of ankle-joint ... . . 11 
 
 2. Linear fracture of tibia in lower third as complication of 
 
 sprained ankle ; illustrating ' sprain- with-fracture ' . 13 
 
 3. Knee-joint permanently flexed and stifE as result of enforced 
 
 movements and exercise while the semilunar cartilage 
 remained displaced . . . . . . .17 
 
 4. Knee-joint fully distended with fluid as result of severe 
 
 sprain .......... 21 
 
 5. Photograph of knee-joint with elastic compression applied 23 
 
 6. Radiogram of fracture of left olecranon without displace- 
 
 ment 39 
 
 7. Photograph of knee showing scar indicating author's line 
 
 of incision for exploratory arthrotomy ... 45 
 
 8. Photograph of old injury to knee-joint with atrophy of 
 
 muscles of the thigh and hypertrophy of those of the calf 49 
 
 9. False joint at hip, result of faulty treatment of fracture of 
 
 the neck of the femur by movement and exercises . 52 
 
 10. Radiogram of fracture of first phalanx of little finger with 
 
 permanent deformity ....... 53 
 
 11. Radiogram of false joint in the lower third of the humerus 
 
 of ball-and-socket type, resulting from too early move- 
 ments at the elbow in the treatment of a fractured arm 54 
 
 12. Radiogram showing ossifying myositis in extensor muscles 
 
 of the thigh 57 
 
 13. Radiogram of same case at a later stage ... 58 
 
 14. Radiogram of extensive ossifying myositis in extensor 
 
 muscles of thigh, result of sprain at football, showing 
 distinct lamination .59 
 
 15. Photograph of thigh with swelling on the extensor surface 
 
 due to mass of ossifying myositis . . . .61 
 
 16. Radiogram of knee-joint with partial detachment of a 
 
 portion of the rim of the external femoral condyle . 67 
 
xiv LIST OF ILLUSTRATIONS 
 
 FIGURE PAGE 
 
 17. Photograph of structures removed from a knee-joint by 
 
 operation in which there was displacement of an internal 
 semilunar cartilage of long standing with chronic 
 synovitis 69 
 
 18. Eadiogram of oblique fracture through lower end of radius 
 
 in which there was no displacement . . . .84 
 
 19. Eadiogram of a fracture of the tip of the styloid process of 
 
 the ulna ......... 85 
 
 20. Eadiogram of sprain-dislocation at the wrist in a child, 
 
 showing separation of the radial epiphysis and tearing 
 
 of the periosteum 86 
 
 21. Complicated sprain of wrist. Greenstick fracture of lower 
 
 radius, and detachment of the tip of the styloid process 
 
 of the ulna 87 
 
 22. Fracture-sprain of wrist. The scaphoid bone fractured 
 
 into three pieces by blow while boxing ... 88 
 
 23. Fracture of scaphoid of wrist into two pieces . . 89 
 
 24. Fracture of scaphoid of wrist (football accident) . . 90 
 25. 1 Eadiograms of Bennett's fractures at the base of the 
 
 26.) metacarpal bone of the thumb 95 
 
 27. Linear fracture of the metacarpal bone of the thumb 
 
 without displacement 96 
 
 28. Eadiogram of fractured first phalanx of index finger . 98 
 
 29. Eadiogram of greenstick fracture of the first phalanx of the 
 
 index finger 98 
 
 30. Eadiogram of a greenstick fracture of the metacarpal bone 
 
 of the second finger, showing well-marked callus as 
 result of rubbing 99 
 
 31. Photograph of a sprained ankle, which had been incorrectly 
 
 bandaged during treatment 102 
 
 32. Eadiogram of sprain of ankle with fracture (linear) through 
 
 the lower third of the tibia 104 
 
 33. Photograph of sprain of knee-joint taken four hours after 
 
 the accident, showing full distension of the capsule . 115 
 
 34. Photograph of case of acute traumatic synovitis of 
 
 knee-joint as result of displacement of the external 
 semilunar cartilage taken two hours after the 
 accident . .117 
 
LIST OF ILLUSTRATIONS xv 
 
 FIGURE PAGE 
 
 35. Photograph of two knees with chronic thickening of the 
 
 synovial membranes in a case of recurrent displacement 
 
 of the semilunar cartilages . . . . . .118 
 
 36. Photograph of anterior half of a semilunar cartilage of the 
 
 knee 125 
 
 37. Photograph of anterior half of a left internal semilunar 
 
 cartilage of the knee 126 
 
 38. Photograph of a drawing from a specimen of an internal 
 
 semilunar cartilage showing longitudinal tearing into 
 three strips 129 
 
 39. Drawing from the upper surface of the head of left tibia 131 
 
 40. \ 
 
 * I Three stages in the author's method of reducing displaced 
 
 * r semilunar cartilages 141 
 
 43. Schemes to illustrate further the method of reduction . 143 
 
 44. Piece of bone detached from the edge of the patella, which 
 
 had become rounded off and formed a loose body in the 
 knee-joint 147 
 
 45. Block of hinge apparatus for the knee .... 150 
 
 46. Photographs of knees to show old transverse scars in the 
 
 removal of semilunar cartilages 152 
 
 47. ] The three stages in the author's operation for exploratory 
 
 48. - arthrotomy and for removal of semilunar cartilages 
 
 49.) from the knee 154, 155, 156 
 
 50. Long-standing displacement of left external semilunar 
 
 cartilage of knee, showing atrophy of muscles of the thigh 
 and hypertrophy of those of the calf, also flexion and 
 fore-shortening of the limb 165 
 
 51. Recent case of displaced external semilunar cartilage, with 
 
 flexion and swelling of the left knee .... 167 
 
 52. Photograph, showing hernia of muscle of thigh . .171 
 
 53. Dislocation of peroneus longus tendon on to the external 
 
 malleolus . . 174 
 
 54. Back view of a displacement of both the peroneus longus 
 
 and brevis tendons from their groove behind the 
 malleolus 175 
 
 55. Strapping applied for rupture of right rectus abdominis 
 
 muscle 189 
 
xvi LIST OF ILLUSTRATIONS 
 
 FIGUEE PAGE 
 
 56. A. Strapping applied for sprained side (intercostal 
 
 muscles), b. Strapping applied for sprain or rupture 
 
 of the oblique muscles of che abdomen — ' bowler's side ' 191 
 
 57. Rupture of the rectus femoris muscle, also old scar for 
 
 removal of semilunar cartilage of the knee . . . 195 
 
 58. Strapping applied for rupture of the hamstring muscles in 
 
 the upper half of the thigh 196 
 
 59. Long- standing case of rupture of the ligamentum patellae on 
 
 both sides with characteristic deformity . . . 204 
 
 60. Radiogram of the left knee of the same case . . 205 
 
 61. Apparatus worn for rupture of both patellar ligaments to 
 
 enable patient to walk . . . . , . 206 
 
 62. Strapping applied for ' tennis-leg ', a rupture of fibres of 
 
 the soleus or plantaris muscles ..... 207 
 
 63. Ankle strapped for strain by author's plan . . . 225 
 
 64. Strapping of shoulder for contusion or sprain , . 226 
 
 65. Elbow-joint with elastic pressure applied for sprain with 
 
 effusion 227 
 
 CHARTS 
 
 1.] Represent the average temperature after arthrotomy of 
 
 2.) the knee-joint when no drainage is used . . 158, 159 
 
 3. 1 Represent the same when drainage of the joint is employed 
 
 4.) for twenty- four hours after operation . . . 160, 161 
 
OF THE 
 
 UNIVERSITY 
 
 OF 
 
 SPRAINS AND ALLIED INJURIES 
 OF JOINTS 
 
 ^ CHAPTER I 
 
 INTRODUCTORY 
 
 The subject of sprains is quite inadequately 
 treated in the ordinary manuals of surgery. Modern 
 methods of diagnosis have taught us much concerning 
 the anatomical conditions underlying strains and 
 sprains, and these injuries can only be adequately 
 diagnosed and treated by their means. The present 
 widely divergent views on the treatment of sprains 
 is itself evidence of the want of exact knowledge 
 concerning the pathological conditions present. On 
 the one hand the bone-setter treats every sprain by 
 massage and movement, while the usual custom 
 among medical practitioners is to treat these con- 
 ditions by rest, the joint being fixed in splints. 
 Both these rule-of-thumb methods may do a great 
 deal of harm. The bone-setter who manipulates 
 a sprain complicated by fracture may displace the 
 fragments, and by his unscientific movements cause 
 an excessive amount of callus to be thrown out, 
 with resulting permanent deformity of the joint. 
 The consequence of putting every sprained joint at 
 rest by fixing it in splints is often equally or even 
 more disastrous. The resulting atrophy of the 
 
 WHITELOCKE 
 
 ^ 
 
2 SPRAINS AND ALLIED INJURIES 
 
 muscles moving the joint, and the formation of 
 adhesions within it, produce not infrequently total 
 disablement of a joint which, with proper treatment, 
 might have recovered entirely. For the last eighteen 
 years the writer has made a special study of these 
 injuries, and has had unusual opportunities of treat- 
 ing a large number of such cases. 
 
 Concerning the Structure and Functions of Joints. 
 Joints are constructed for movement. The bones 
 which enter into their formation are covered with 
 a thin layer of smooth, highly polished, hyaline 
 cartilage. This enables them to move smoothly 
 upon one another with a minimum of friction, and 
 no jarring. They are tensely and firmly bound 
 together by the ligaments and tendons which 
 surround them. The capsule which envelops the 
 ends of the bones is invariably continuous with 
 the periosteum, and securely encloses them in what 
 is but a potential space. The capsular ligament is 
 lined by the synovial membrane, which extends to 
 the edges of the cartilaginous border. This mem- 
 brane is polished, and lined on its visceral surface 
 by endothelium, and serves to secrete a fluid which 
 lubricates the inner surface of the joints. It is 
 thrown into folds wherever it is not in contact with 
 the articular surfaces, and is covered with villi, or 
 papillae, which, in certain conditions of disease, are 
 liable to thickening and hypertrophy. The inter- 
 articular ligaments are closely enveloped by it. It 
 secretes a viscous fluid known as synovia, the chief 
 constituent of which is mucin. The function of 
 synovia is that of a lubricant. The bones, cartilages, 
 ligaments, periosteum, synovial membrane, and, in 
 
INTRODUCTORY 3 
 
 fact, all the tissues which enter into the formation 
 of a joint, are developed from a common embryonic 
 origin, the mesoblast ; hence, in certain cases of 
 injury, and as a result of certain pathological states, 
 they become interchangeable and take the place of 
 one another, though to a limited extent. 
 
 The villi of the synovial membrane may develop 
 cartilage, or even bone, when unduly stimulated, and 
 the ligaments may undergo ossification. A healthy 
 joint contains but a potential cavity. This becomes 
 a real one if the capsule should be distended either 
 with blood or serous effusion, in consequence of 
 injury or disease. Such distension gives rise to 
 stretching and elongation of the ligaments, allowing 
 of greater movement between the bones, while the 
 joint becomes weakened and unstable, and more 
 liable to injury. The synovial cavity empties itself 
 through stomata into the lymphatics, which pass 
 through the capsule and enter the lymph spaces in 
 the inter-muscular and fascial strata. Blood is 
 freely supplied by the articular vessels. The nervous 
 supply of a joint is generally the same as that for 
 the muscles which act upon it, and for the skin over 
 its surface. The importance of this interesting 
 physiological relationship will again be referred to. 
 
 The strength of a particular joint depends upon — 
 
 (1) the arrangement of its bony surfaces one to 
 the other ; 
 
 (2) the nature, strength, and disposition of its 
 ligaments ; 
 
 (3) the muscles and tendons which surround it ; 
 
 (4) its normal amount of mobility. 
 
 Some joints derive their stability from the accurate 
 
 B 2 
 
4 SPRAINS AND ALLIED INJURIES 
 
 adaptation of the opposing bony surfaces to one 
 another. The ball-and-socket arrangement of the 
 hip, and the hinge of the elbow, are mainly respon- 
 sible for the great strength of these articulations. 
 It requires very great force to dissociate or undo the 
 bony apposition, and dislocations are rare without 
 being associated with serious ligamentous tearing or 
 fracture of one or other bone. 
 
 On the other hand one may cite such an articula- 
 tion as the shoulder, a joint quite devoid of any 
 bony influence, and dependent entirely for its 
 integrity upon the strength of its ligaments and the 
 muscles enveloping and tendons passing over and 
 around it. A very trifling amount of violence 
 exerted unexpectedly, catches, so to speak, the 
 muscles unawares and the bones in an unusual 
 position, and is sufficient to produce a complete 
 dislocation. The very range of movement enjoyed 
 by the shoulder is its source of weakness ; for what 
 it gains in mobility it loses in stability. Between 
 these two extremes is an intermediate group of 
 joints, dependent, on the one hand, partly on the 
 formation of their bony surfaces, and partly on the 
 support afforded by the muscles and tendons that 
 envelop or surround them. The knee, wrist, clavi- 
 cular, tarsal, carpal, and many other smaller articu- 
 lations, derive their strength mainly from the liga- 
 ments which firmly bind their several bones together. 
 It is in this group that we meet for the most part 
 with strains and sprains. When such a joint is 
 subjected to external violence, whereby strain is 
 put upon it, the brunt has to be borne by the liga- 
 ments. If the violence is slight, pr the ligament 
 
INTRODUCTORY 5 
 
 a strong one, nothing more serious than an over- 
 stretching or strain results ; if, on the other hand, 
 the violence is extreme, not only individual ligaments, 
 but whole groups of ligaments may be completely 
 torn across. This class is represented by those 
 joints whose chief strength is derived from their 
 ligaments. 
 
 Some joints possess inter- articular cartilages which, 
 though technically ligaments, since they bind bones 
 to bones, are a source of natural strength in an 
 indirect way. The amount of gliding or similar 
 movements allowed by these inter- articular structures 
 serves often to turn off, as it were, the main strain 
 into some other direction as soon as violence is 
 brought to bear on them. While every variety of 
 joint is liable to sprain, it may be stated generally 
 that those joints dependent on the strength of their 
 ligaments are those most prone to this form of 
 injury. 
 
CHAPTER II 
 
 SPRAINS CONSIDERED GENERALLY 
 
 All classes of society are liable to sprains, the 
 rich as well as the poor. They are very frequently 
 met with, and although they cannot be classed as 
 accidents of a dangerous kind, they are nevertheless 
 serious. Great numbers of persons are incapacitated 
 from their daily calling, wage-earners as well as 
 pleasure-seekers. There is, perhaps, no more fruit- 
 ful field than the athletic. For some inexplicable 
 reason, the importance due to such crippling ailments 
 has been little considered by surgeons in the past. 
 Such disablements, in the vast majority of cases, 
 seem to have been relegated to the rule-of-thumb 
 attentions of the bone-setter, a class of persons with 
 little or no scientific training or interests. 
 
 At the present time, when the achievements of 
 modern operative surgery everywhere resound, and 
 new advances are made in different departments, 
 in the scientific as well as the practical, these so- 
 called ' little things ' of minor surgery are apt to 
 be neglected and considered as of subsidiary impor- 
 tance. Yet, if the wage-earning capacity of the nation 
 is taken into consideration, the annual loss must be 
 enormous, and under the new Workmen's Com- 
 pensation Act the expenses of the employers of 
 labour are not likely to be diminished. This latter 
 consideration, perhaps more than any other, may 
 
SPRAINS CONSIDERED GENERALLY 7 
 
 in the future redirect the attention of surgeons to 
 a branch of surgery which, to say the least of it, 
 has been somewhat neglected. Already there are 
 signs that the empiricism of the much-consulted 
 and the much-in-request wiseacre or bone-setter, 
 the person who invariably finds ' something out of 
 place ', ' a bone out of joint ', and whose stock treat- 
 ment is to ' move everything ', is giving way slowly, 
 though surely, to a more rational and, if one may 
 be permitted to say so, scientific and discriminating 
 regime. Nevertheless, there are still thousands of 
 persons, men and women of education and culture, 
 who resort to these unregistered, irresponsible prac- 
 titioners, and consult them with a confidence that 
 is truly surprising. 
 
 It surely behoves our profession to pause, con- 
 sider, and make inquiries, as to whether means may 
 not and should not be taken to remedy this state of 
 things ; for not only is it an opprobrium to ourselves, 
 but hundreds of people, owing to improper rule-of- 
 thumb and irresponsible treatment, are rendered 
 permanently incapacitated and crippled. The vic- 
 tims, unprotected by the legislature of the country, 
 often find out their mistake when the time for 
 remedial measures is past, with frequently a legacy in 
 the shape of a damaged limb for the rest of their lives. 
 
 Definition. When the movements in a joint are 
 carried beyond their normal and physiological limita- 
 tions, owing to some wrenching or twisting form of 
 violence, and the soft structures which bind the 
 component bones together are overstretched or 
 torn across, such an injury is said to be a strain or 
 sprain. At one time the classical conception of 
 
8 SPRAINS CONSIDERED GENERALLY 
 
 a sprain was ' a wrench or strain resulting in stretch- 
 ing or laceration of the soft parts without external 
 wound '. Such a definition at the present time 
 requires some modification, for although in the main 
 it is an accurate description of the anatomy of the 
 affection, yet there is a certain proportion of cases 
 which, formerly classified with sprains, would at the 
 present time be more properly grouped with frac- 
 tures. For example, in the injuries to the larger 
 joints it is not an uncommon experience to find 
 small fragments of bone detached with the ligaments 
 where they have been torn from their periosteal 
 attachments. Again, in the smaller articulations, as 
 those of the wrist, hand and foot, the small bones 
 may be fissured, chipped or even crushed ; so also 
 small epiphyses are sometimes dragged away by 
 the tendons in muscular sprains. 
 
 The use of the X-rays as a means of diagnosis has 
 revealed many such bony defects where formerly 
 they might not have been suspected. For clinical 
 purposes, however, these injuries may still be 
 regarded as sprains, for the symptoms of fracture 
 are of minor importance as compared with those of 
 sprain, which usually greatly predominate. Their 
 true pathological significance must never be lost 
 sight of nevertheless, for the existence of a fracture 
 however slight materially changes the treatment. 
 To this, reference will be made later, when the 
 question of treatment is under consideration. 
 
 Classification. For the purposes of classification, 
 sprains may be divided into two large classes. 
 
 1. Articular, or those affecting the joints them- 
 selves ; 
 
^ 
 
 UNIVERSITY 
 
 OF. 
 
 SPRAINS CONSIDERED GENERALLY 9 
 
 2. Muscular, concerned with the overstretching, 
 dislocation or rupture of muscles and their tendons. 
 
 1. Articular Sprains, for clinical purposes, may 
 be arranged into two divisions or classes : (a) simple, 
 (h) complicated. 
 
 (a) Simple Sprain, By the term ' simple sprain ' 
 is here meant only those cases where, as the result 
 of some external violence, the soft parts are over- 
 stretched or torn across, and in which no gross 
 lesion of the bone is to be found. 
 
 In the simplest form of sprain, that technically 
 described as strain, the soft parts are merely stretched 
 beyond their usual capacity, and there is no true 
 laceration. No swelling is to be found, and the 
 symptoms are only those of pain and stiffness with 
 some loss of function. 
 
 In the more severe forms of simple sprains, in 
 which there has been more or less tearing, as well as 
 stretching of the ligaments and other structures of 
 the joint, in addition to pain and loss of power, we 
 get swelling. When the swelling follows immediately 
 after an injury it is due to haemorrhage. Arteries 
 as well as veins are torn across, and pour their 
 contents into the tissues around. Haemorrhage is 
 sometimes, as we shall see when dealing with mus- 
 cular sprains, of large amount and serious conse- 
 quence. The bleeding usually ceases as the tension 
 in the parts increases, but it sometimes happens that, 
 when the injured vessel is a comparatively large 
 and important one, and when the tissues into which 
 it drains are loose and distensible (as may be met 
 with in some of the fascial planes of the body), 
 it may continue for a considerable time after the 
 
10 SPRAINS CONSIDERED GENERALLY 
 
 injury, and give rise to extensive swelling. Haemato- 
 mata result from the blood clotting in the tissues. 
 
 When the swelling in a joint comes on some hours 
 or it may be even days later, it is due to serous 
 effusion, and is known as ' deferred swelling '. 
 This varies considerably in amount in different 
 cases, depending upon a variety of causes such as the 
 nature and severity of the injury, health and idio- 
 syncrasy of the individual, and sometimes even to 
 improper treatment early in the case. It is regarded 
 by some authorities as inflammatory in nature ; by 
 others, as a necessary concomitant, and as afford- 
 ing more of a physiological than a pathological 
 significance, and even of being concerned in the 
 process of repair. 
 
 There is something to be said for both views. 
 That it is of pathological significance it must be 
 admitted, since it is the result of injury and is only 
 present to any appreciable quantity when diseased 
 conditions coexist. 
 
 (b) Complicated Sprains, 
 
 I. Simple sprains become complicated when 
 there are gross injuries to the bone or its periosteum, 
 as when portions of bone or epiphyses are detached, 
 and when the bones are fissured or even crushed. 
 Such a lesion is now loosely designated a sprain- 
 fracture, or fracture-sprain. It should, however, be 
 clearly understood that there is a marked differ- 
 ence between a fracture-sprain and a sprain with 
 fracture. 
 
 When the sprain is complicated by an injury to a 
 bone entering directly into the joint, or to a neigh- 
 bouring epiphysis, it is called a fracture-sprain or 
 
SPRAINS CONSIDERED GENERALLY 11 
 
 sprain-fracture. If in addition to the sprain of 
 a joint there is a fracture of one of the bones in 
 its immediate neighbourhood but not involving the 
 joint itself, the expression sprain with fracture may 
 
 Fig. 1. Fracture-sprain of ankle — note the separation through the 
 internal malleolus — taken from a boy of 14. The lower epiphysis of tibia, 
 including the malleolus, is normally developed in one piece. Accident 
 the result of a twdst of the joint. To illustrate sprain-fracture. 
 
12 SPRAINS CONSIDERED GENERALLY 
 
 be used. Figs. 1 and 2 illustrate these definitions, 
 and should be compared. 
 
 2. In some joints, such as the knee, tempero- 
 maxillary, and clavicular, in which inter-articular 
 cartilages are to be found, it is no uncommon 
 circumstance for these structures to become partially 
 detached or torn across and displaced, either inwards 
 towards the cavity, or out of the joint. Though 
 technically a semiluxation or partial dislocation, 
 since the symptoms of sprain so greatly predominate, 
 it has been customary to regard such an accident 
 as a sprain, and to treat it as such. This, from 
 analogy, may be styled a strain-dislocation, 
 
 3. In a few cases the nerves suffer injury and 
 complicate matters. They may be overstretched, 
 resulting in temporary paresis, or a sensation of 
 numbness may be experienced in some branch far 
 removed from the injured joint. Pain is generally 
 the chief symptom when nerves are pressed upon 
 by inflammatory exudation, or overstretched in 
 some part of their course. It may be localized to 
 the seat of injury, or radiate along a nerve-trunk 
 around the body or into the extremities. If not 
 detected early, or if improperly treated, this com- 
 plication gives rise to serious and prolonged crippling. 
 A form of chronic atrophic neuritis may supervene, 
 and atrophy of the muscles supplied by the special 
 nerve, of a peculiar and lasting kind, result. Unless 
 carefully sought for at the time, such lesions are apt 
 to be overlooked by the surgeon, for patients seldom 
 attach importance to sensations referred to parts 
 of the body distantly removed from the main injury ; 
 nor is it difficult to miss some small area of numbness 
 
SPRAINS CONSIDERED GENERALLY 13 
 
 or altered sensation in the skin. When large or 
 important nerves, such as the sciatic, or branches 
 of the brachial plexus are concerned, for obvious 
 
 Fig. 2. Linear fracture of tibia in lower third without displacement, 
 from a boy who walked into hospital complaining of having sprained his 
 ankle. The fracture does not extend to the joint. To illustrate author's 
 ' sprain-with-fracture '. Radiogram taken two days after the accident. 
 
 reasons the symptoms are more readily noticed. 
 It is therefore a wise precaution in all severe sprains 
 
14 SPRAINS CONSIDERED GENERALLY 
 
 for the surgeon to direct his attention towards 
 searching for possible nerve lesions. 
 
 4. Sprains with very large hsematomata may 
 be regarded as complicated sprains, for they may 
 require even operative measures for their successful 
 treatment. Large collections of effused blood are 
 met with not infrequently as the result of sprains 
 and lacerations of muscles ; especially in situations 
 where there is little resistance offered to the extra- 
 vasated blood, as afforded by the loose planes of 
 cellular tissue between groups of muscles, as those 
 of the thigh and abdomen, and the sheath of the 
 psoas and iliacus. 
 
 Diagnosis. The importance of an early diagno- 
 sis in all cases cannot be too strongly advocated, 
 nor can this advice be too often repeated. It may 
 not always be possible to make an exact or complete 
 diagnosis, but to get as near to the truth as possible 
 should be the first aim. The difficulty or otherwise 
 in arriving at a correct diagnosis will depend largely 
 upon the period at which the surgeon is called to 
 see the case. If he is fortunate enough to be con- 
 sulted before such swelling has taken place, his 
 task may be comparatively simple ; on the other 
 hand, when much material has had time to be poured 
 out into the surrounding tissues and increased by 
 subsequent inflammation, his difficulties may be 
 almost insurmountable. It is always a sound plan, 
 when in doubt, to completely anaesthetize the 
 patient. This should be done in all cases where 
 there is no potent contra-indication such as the 
 presence of advanced organic disease or insuperable 
 objection by the patient. The joint should then be 
 
SPRAINS CONSIDERED GENERALLY 15 
 
 put through all its movements. In doing this the 
 synovial membrane will be put fully on the stretch, 
 and any folds which may have been made will be 
 unfolded, the curling in of torn fragments of the 
 capsule replaced (and this is no uncommon occur- 
 rence), and any undue fixity or abnormal mobility 
 of the joint itself noted. 
 
 When the inter-articular fibro-cartilage has been 
 torn or displaced, the movements, at first limited 
 and incomplete, may be at once restored by a free 
 and painless manipulation. 
 
 Crepitus may or may not be elicited, and it is of 
 importance to direct attention to this important 
 symptom. The absence of or failure in detecting 
 crepitation does not at once dispose of the possi- 
 bility of fracture any more than does its presence 
 give positive proof of its existence. By this is 
 meant that there are cases of fracture in which 
 crepitation cannot by any means be detected, such 
 as in fissured injuries of bone, while it is often 
 distinct and quite easily palpable in joints the 
 subject of osteo-arthritis, or where sticky material 
 is effused into tendon-sheaths in the neighbourhood 
 of injured joints, and where no fracture exists. 
 Where there is no fracture, unusual mobility will 
 give the observer a fair estimate of the amount of 
 damage sustained by the ligaments as a whole, as 
 well as by the particular ligament, or group of 
 ligaments, which have borne the brunt of the inci- 
 dence of the violence. Having ascertained all that 
 can be learned by manipulation with the aid of a 
 general anaesthetic, if it be possible or practicable, 
 the limb or part should be examined by means of the 
 
16 SPRAINS CONSIDERED GENERALLY 
 
 X-rays, under the management of a competent 
 person, and I say competent advisedly, for the 
 correct interpretation of a radiogram requires con- 
 siderable surgical knowledge and practice. The 
 X-rays will settle once and for all the existence 
 or otherwise of a fracture, a point of incalculable 
 service, as will be noted when treatment is considered. 
 The X-ray photograph should be taken from different 
 points of view, or it may fail to show a fracture. 
 
 A sprain complicated with injury to a bone or 
 displaced, torn, or otherwise detached inter-articular 
 cartilage, or with gross nerve lesion, or exten- 
 sive extravasation, will require special and careful 
 handling. 
 
 Prognosis. The immediate prognosis in the case 
 of simple sprains and strains is good, but in com- 
 plicated cases some caution must be exercised. 
 
 Sprain-fractures, when not detected and when 
 treated by ordinary means like simple sprains, may 
 lead to prolonged stiffness and much unnecessary 
 suffering. So in cases of gross nerve lesion, continued 
 pain and muscle atrophy, even of a permanent kind, 
 may supervene, as well as actual local paresis or 
 palsy. Disorganization of a knee-joint has been 
 known to result from enforced exercises in a case 
 of undetected displaced semilunar cartilage (Fig. 3). 
 These extreme cases, however, are rare. 
 
 Certain remote contingencies arise which are quite 
 beyond the control of the surgeon, such as osteo- 
 arthritis, myositis ossificans, palsy, tumour or tuber- 
 culosis, loose bodies in the joint, as well as others, 
 such as deformity, which can be, for the most part, 
 prevented. These remote and permanent conse- 
 
SPRAINS CONSIDERED GENERALLY 17 
 
 quences will be referred to again when dealing with 
 the sequelae of sprains. Prognosis is daily becoming 
 of much practical importance. The new Workmen's 
 
 Fig. 3. Photograph of knees. The left shows permanent flexion and 
 stiffness, result of unreduced semilunar cartilage. Owing to mistaken 
 diagnosis case had been treated at a gymnasium for many months with 
 movements, exercises, and massage. Patient now quite lame. Correct 
 diagnosis had not been made in the first instance, as he was treated by 
 a bone-setter. 
 
 Compensation Act makes it almost imperative that 
 surgeons should be able to give a reliable opinion in 
 cases of injury. 
 
 Treatment. Simple sprains, as distinguished from 
 
 c 
 
 WHITELOCKE 
 
18 SPRAINS CONSIDERED GENERALLY 
 
 sprains complicated with lesions of bone or nerve, 
 are of two classes : those in which pain, stiffness, and 
 loss of function are the only symptoms, and those in 
 which there is swelling in addition. For the former 
 class the term ' strain ' is used. 
 
 Simple strains are for the most part limited to 
 strains about joints and to the muscles of the back 
 and neck, and the short flat muscles of the trunk. 
 They are not a large class. Those suffering from 
 strains seek assistance mainly for the relief of pain, 
 which may be intense. Absolute rest to the injured 
 part is the first indication where pain is concerned, 
 jand this may best be attained by the aid of strapping. 
 Various materials are used for this purpose. The 
 best are those which give a more or less resilient or 
 elastic support, such as wash-leather strapping and 
 leucoplast. Mead's or Leslie's plaster may be used, 
 but do not answer the purpose so well ; they are, 
 however, much cheaper. Perhaps, all things con- 
 sidered, Seabury's adhesive perforated rubber plaster 
 is the most universally applicable ; it is strong, 
 allows of evaporation, and is not quite as irritating 
 as some other forms ; it has a further advantage of 
 being comparatively cheap, and may be had in 
 convenient sizes. All strapping must be carefully 
 and evenly applied, so as to ensure perfect rest to 
 the parts concerned. As soon as the pain ceases, 
 or is materially lessened, gentle stroking massage 
 may be employed twice or of tener in a day. Massage, 
 in some instances, will further reduce pain, but 
 slight voluntary movements should be encouraged 
 from the very first, as thereby stiffness, the other 
 symptom of strain, is readily and speedily overcome. 
 
SPRAINS CONSIDERED GENERALLY 19 
 
 and the healthy physiological nutrition of the joint 
 or muscle promoted, with complete restoration to 
 function. 
 
 Sprains with ^ immediate swelling '. Bleeding into 
 the tissues follows almost immediately upon the 
 injury, the blood being poured out from the ruptured 
 vessels. The swelling is usually established before 
 the surgeon is called to the case. If, however, the 
 case is seen early, an attempt should be made to 
 arrest or check further haemorrhage. Various means 
 have been employed to effect this, and while one 
 practitioner will employ cold as a routine, another 
 will, with equal confidence, use nothing but warm 
 applications. The writer has for years entirely 
 abandoned the use of either cold or hot applications — 
 neither is, in his opinion, sufficiently efficacious. 
 Cold, to be of any real value, must be continuous and 
 intense, and this is not without danger to persons 
 suffering with organic (cardiac or renal) disease. 
 Cases are on record where extensive sloughing has 
 followed upon the continued use of cold in persons 
 suffering from albuminuria, glycosuria and other 
 debilitating affections. Warm amplications are better 
 tolerated, and even liked by patients, but they 
 would only seem to encourage rather than check 
 the extravasation of blood. Any application of 
 heat that would be sufficient to reflexly pro- 
 duce contraction and retraction of the torn ends 
 of deeply situated blood-vessels, would not be 
 borne with any comfort, nor would this be safe 
 as a routine proceeding. The skin of some indi- 
 viduals is peculiarly liable to be damaged by high 
 degrees of temperature, whether the heat is dry or 
 
 c 2 
 
20 SPRAINS CONSIDERED GENERALLY 
 
 moist. The most efficacious, and at the same 
 time the most readily appHed remedy is firm elastic 
 pressure. Elastic pressure is suitable for all cases 
 of extravasation, whether of little or great amount, 
 whether immediate or deferred. It has the advan- 
 tages of being absolutely safe, easily applied, and of 
 universal application ; it ensures perfect rest, and 
 if employed immediately or soon after an injury, 
 decidedly diminishes or completely prevents those 
 secondary effusions so apt to follow. Furthermore, 
 it promotes, to a marked degree, the rapid absorption 
 of extravasated material, the next great desideratum 
 in the treatment of all kinds of sprains. Thus, 
 by insuring rest, checking or limiting immediate 
 haemorrhage, preventing or at any rate diminishing 
 secondary effusion, promoting the absorption of all 
 extravasated material, it serves the double purpose 
 of meeting the two first and all-important desiderata 
 — those of checking haemorrhage and removing 
 extravasations. When properly applied, it takes the 
 place of a splint and ensures rest ; its mode of action 
 may be observed in the treatment of contusions. 
 The principle is simple : in applying equable elastic 
 pressure of a higher degree than that of the blood 
 pressure, the escape of material from the blood- 
 vessel is mechanically prevented, and this pressure, 
 exerted on the fluid materials that have already 
 escaped into the tissues being greater than that of 
 the blood pressure in the vessels themselves, it 
 happens that a process of re-absorption is soon 
 initiated and the swelling is observed to subside 
 apace. The same principle is at work in relation 
 to the serous effusion which is almost invariably 
 
SPRAINS CONSIDERED GENERALLY 21 
 
 poured out secondarily into the synovial cavities 
 of the larger joints. It is maintained that if elastic 
 pressure can be properly and immediately applied 
 to an injured joint, it is unusual to have secondary 
 effusions, and when such effusions do take place they 
 
 i'lG. 4. Photograph of knee-joint in profile, taken two hours after 
 
 severe sprain. 
 
 do so to a more limited extent than when other 
 remedial measures are adopted. 
 
 It may be used for any extravasation or effusion, 
 whether localized or diffused, whether of rapid or 
 more chronic formation. It matters not whether 
 the material is confined within the capsule of the 
 joint, or merely loosely collected in the inter- muscular 
 and cellular planes of the trunk or extremities. The 
 
22 SPRAINS CONSIDERED GENERALLY 
 
 action is the same ; its service invariably efficient. 
 If a joint such as the knee be taken as an illustration, 
 and if we suppose that, as the result of a twist, its 
 capsule has become fully distended with effusion^ 
 and that most of the swelling took place immediately 
 after the accident and continued to gradually increase 
 for some hours afterwards, it will be found that such 
 a knee assumes the posture of slight flexion (Fig. 4). 
 This is a position which, from the nature of things, 
 permits of the greatest relaxation of the muscles 
 around the joint, and allows to the distended capsule 
 its fullest capacity, and in this way best assures relief 
 to the sufferer. 
 
 This is nature's first attempt at procuring rest,, 
 our first requirement in treatment ; to extend such 
 a joint and fix it in the straight position in a splint^ 
 as is so often recommended and practised, would 
 not only violate this principle of securing rest, but 
 render the patient exceedingly restless and uncom- 
 fortable. On the contrary, the limb should be left 
 in the position that it naturally assumes, which is 
 always that which is most comfortable to the patient. 
 When the knee is partially bent, not only are the 
 muscles relaxed, but the surrounding ligaments are 
 also slackened ; when, on the other hand, it is 
 extended, these tissues are tightened up and exert 
 pressure on the distended capsule, thereby tending 
 to increase the pain and discomfort. 
 
 Method of applying Elastic Pressure. To the 
 slightly flexed limb thick layers of cotton- wool are 
 adapted. They are either rolled aroimd the joint,^ 
 or cut into shapes and so applied that a complete 
 coating of at least one inch of thickness is attained. 
 
SPRAINS CONSIDERED GENERALLY 23 
 
 In length, the material should extend for at least 
 two inches above and below the outside limitations 
 of the capsular ligament. Gamgee-tissue, though 
 more expensive, answers the purpose admirably ; it 
 may be cut with greater nicety and exactitude than is 
 ordinary cotton-wool, and so adapted more easily to 
 the varying requirements. Over this thickness of 
 material a strong roller bandage is tightly applied ; 
 an inelastic yet resilient material, such as a domette 
 
 Pig. 5. Photograph of knee with elastic pressure appUed for sprain. 
 Author's plan. The knee is here represented as being too straight, it 
 should be more flexed. 
 
 or soft flannel bandage is all that is necessary. Stout 
 calico or crepe- velpeau bandages are less useful, the 
 former variety being a little too stiff, while the latter 
 too soon lose their elasticity and become over- 
 stretched and unsuitable. 
 
 The bandage is then drawn as tightly as possible 
 over the wadding so as to compress it to its utmost 
 capacity, then fixed, to maintain it in this position. 
 Great care must be taken to avoid creases in the 
 wool, and to see that it is smoothly and equally 
 applied, otherwise the pressure will not be evenly 
 distributed. Four inches is a useful breadth for 
 
24 SPRAINS CONSIDERED GENERALLY 
 
 a bandage when applied to the trunk or lower ex- 
 tremity ; a narrower one is more suitable for the 
 upper limb. The photograph represents a knee-joint 
 with elastic compression applied. 
 
 It is of great advantage, whenever it is possible, to 
 remove the bandage about six hours after its first 
 application, and to thoroughly re-examine the joint. 
 Oftentimes, points of diagnostic significance are lost 
 sight of when making the first examination. By 
 this time, in many cases, tension will have already 
 become less, the patient less alarmed, and, finding 
 his pain considerably diminished, will allow the 
 surgeon more manipulative access to his injury. It 
 may be assumed that whilst the first application of 
 the elastic pressure mainly checks extravasation, the 
 second and subsequent ones promote its re-absorption. 
 It is well for the first three or four days, when practic- 
 able, to remove the bandage twice in the twenty- 
 four hours. The surgeon is thus enabled to judge of 
 the rapidity or otherwise of the process of absorption, 
 and what is of greater importance is that the inter- 
 mittent removal and re-application of the bandage 
 has a direct infiuence on the local circulation. As 
 soon as the bandage is removed, the part that has 
 been under compression becomes flushed with a new 
 supply of arterial blood richly oxygenated, whilst, 
 on its re-application the veins and lymphatics are 
 once more compressed and their contents thereby 
 emptied into the general blood-stream. This to-and- 
 fro flushing and depletion will be seen to be most 
 beneficial, both in improving the nutrition and 
 assisting absorption. It has been noticed, whether 
 this is a true explanation or not, that swellings are 
 
SPRAINS CONSIDERED GENERALLY 25 
 
 more rapidly reduced in cases where the pressure 
 has been intermittently applied than in those where 
 it has been allowed to remain constant, and this is 
 truer and more certain when the method has been 
 adopted during the early stages of treatment. In 
 most cases the effusion will disappear in about four 
 days, but such a happy result depends largely upon 
 the time in which treatment is commenced, and upon 
 the care and time that the surgeon is able to bestow 
 in carrying out the details. 
 
 The writer seldom uses massage in his practice 
 until all or most of the effusion has disappeared. 
 All that massage can effect, elastic pressure will, if 
 properly and intelligently used. Where there are 
 large haematomata in the tissues, or there is reason 
 to suspect the presence of much clotted blood in a 
 joint, the process of absorption must be expected to 
 take longer. It is in these particular cases that the 
 later use of massage, combined with elastic pressure, 
 is most valuable. It has been said that elastic 
 pressure is painful, that it produces numbness, that 
 it is not well borne and for this reason should not be 
 recommended. This is incorrect, and it may be here 
 necessary to give a word of warning. Unless there 
 is a sufficient thickness of the wadding, and unless 
 the bandage is applied so that it does not come 
 within at least one inch of the upper or lower limits 
 of the wadding, painful constriction due to strangu- 
 lation may result and produce discomfort. Pressure, 
 when properly applied, is never uncomfortable ; it 
 is rather the reverse. A strong elastic rubber 
 bandage should never be used. It is hot, allows 
 of little or no evaporation, is too powerful, causes 
 
26 SPRAINS CONSIDERED GENERALLY 
 
 too much compression and is often most uncomfort- 
 able. Rigid splints and fixed apparatus, whether 
 made of wood, plaster, or other material, should 
 never be employed, even in complicated cases such 
 as sprain-fracture. 
 
 The primary object in the treatment of a joint is 
 to restore its mobility, to avoid the possibility of 
 adhesions forming in it or around it whereby it may 
 become stiff or weak or painful. Much wasting of 
 the surrounding muscles is apt to take place in a 
 joint that is fixed in a splint. This is a serious com- 
 plication, and must be prevented by all means. 
 When the fluid effusion has been materially reduced, 
 or for the most part removed, and the torn ends of 
 the bleeding vessels have had time to be effectually 
 sealed off, then, and not until then, should massage 
 be employed. It is not usual to begin massage until 
 at least seventy-two hours have elapsed. At first, 
 gentle stroking massage should be tried for a few 
 minutes, and then the bandage re-applied. If at the 
 next inspection the fluid is still further diminished, 
 and there is no heat in the joint, friction massage 
 should be combined with stroking movements. 
 This serves to break up the coagula and further 
 disperse the absorbable elements of the clot into 
 the surrounding tissues, and to promote more rapid 
 absorption. 
 
 Active voluntary movements, though at first slight, 
 should be allowed from the very beginning, as 
 soon as the bandages are removed, as they are of 
 primary importance in preventing adhesions and 
 muscle-wasting, and of maintaining the proper 
 nutrition of the structures of the articulation. They 
 
SPRAINS CONSIDERED GENERALLY 27 
 
 relieve rather than cause pain, in most instances ; 
 they should be permitted early in the case only in 
 those muscles that have escaped injury, and their 
 range should be small and limited. 
 
 Passive movements are useful in a mechanical 
 way, but possess little or no physiological merit. 
 By stretching out the synovial membranes and 
 capsular ligaments, they aid in restoring to their 
 natural position fibres that are curled inwards and 
 likely to form new and faulty attachments. Some- 
 times they occasion pain, but they are not to be 
 compared with active or voluntary movements as. 
 regards their influence upon nutrition. The normal 
 nerve-impulse, transmitted to the region of the joint 
 through the muscles, will do more than any mechani- 
 cal means, such as massage and passive movements, 
 to restore physiological action and maintain the 
 processes of repair. This fact should be steadily 
 kept in view in dealing with other injured tissues 
 of the body. 
 
 When a distinct interval of hours and even day& 
 occurs between the time of injury and the inci- 
 dence of swelling, and in those cases where there 
 is a recrudescence of symptoms after a period of 
 apparent subsidence, it is probably due to secondary 
 inflammatory changes. The treatment will depend 
 upon whether or not there are present other signs of 
 inflammation, such as pain on local pressure, heat^ 
 and increased tension. 
 
 In the absence of these acute symptoms, massage, 
 or even movements both passive and active, may 
 be persevered with. Especially useful are the gradu- 
 ally increased voluntary movements and exercises 
 
28 SPRAINS CONSIDERED GENERALLY 
 
 assisted by elastic pressure. If, on the other hand, 
 there is pain accompanied by a distinct rise in the 
 surface temperature of the part, whether in the case 
 of a joint or other part, all movements and massage 
 should cease at once, and reliance be placed entirely 
 upon the use of elastic pressure. The amount of 
 pressure must be carefully regulated according to 
 the degree of comfort or otherwise that it affords. 
 A carefully applied crepe- velpeau bandage adjusted 
 over a fair thickness of gamgee-tissue will not only 
 give absolute rest to an inflamed joint, but will allow 
 it to assume that degree of flexion which is at 
 the same time the most comfortable. It is in this 
 particular class of cases that a fixed and rigid appara- 
 tus is most baneful ; the limb often from the method 
 of its fixation in an extended position becomes 
 uncomfortable ; the discomfort arising in this way 
 leads the surgeon to believe, in many instances at 
 any rate, that he has to deal with a progressive 
 inflammation with increase of tension. Assuming 
 this to be a likely explanation of the symptoms, the 
 splints are indefinitely retained by him, with the 
 result that adhesions form, muscles waste, and a 
 painful, stiff and crippled joint remains. 
 
 These relapsing cases, if the term is used strictly 
 in this special sense, are not infrequently associated 
 with and dependent upon the health of the individual. 
 Persons of a gouty, rheumatic, tubercular, or even 
 syphilitic tendency, are subject to effusions in their 
 joints, the injury being merely the localizing cause. 
 Nor must haemophilia be forgotten. It becomes of 
 the greatest importance, therefore, to make careful 
 inquiry into the histories of all recurrent or relapsing 
 
SPRAINS CONSIDERED GENERALLY 29 
 
 cases, to search diligently and carefully for any other 
 clue which may be corroborative of a suspicion as 
 to constitutional taint. In a large percentage of 
 cases such taint will be readily found, a fact 
 which will greatly influence our views of the local 
 treatment. 
 
 In rheumatic persons pain without effusion is often 
 to be met with. The following case may be used as 
 an illustration. An undergraduate, thrown from his 
 horse while hunting, fell heavily upon his right side, 
 jarring the right hip-joint. He was able to continue 
 hunting for a short run, when he felt his hip- joint 
 becoming increasingly stiff. Returning to college he 
 had a very hot bath, went to bed, and sent for the 
 writer. A careful examination with an anaesthetic 
 was considered advisable and immediately made. 
 No fracture or dislocation was discovered. Treated 
 as a sprain, the joint rapidly improved, and the 
 patient was able to resume gentle riding exercise 
 fourteen days later. For the first ride or two he 
 suffered no inconvenience whatever, and believed 
 that he had completely recovered. He was then 
 pressed by his friends into taking part in a football 
 match, and went down by train for the piu-pose to 
 his old school. He played in his accustomed place 
 and thoroughly enjoyed the game. On his return 
 to Oxford that evening the joint became once more 
 stiff and exceedingly painful. Fearing lest the 
 presence of some slight fracture had escaped detec- 
 tion during the manipulation under the anaesthetic, 
 or some other complication, the X-rays were used. 
 Nothing of the nature of a fissure could be detected 
 in the bones of the pelvis or thigh. As the pain 
 
30 SPRAINS CONSIDERED GENERALLY 
 
 became not only more severe but almost constant, 
 and putting aside the probability of either a gouty 
 or syphilitic taint, since he was an exceptionally 
 healthy and clean living man, the patient was put 
 under the influence of the salicyates and aspirin in 
 large doses. The next morning, and as soon as he 
 had taken as much as 40 grains of salicine and 30 of 
 aspirin, he stated that he ' was cured '. After a few 
 days he ceased to take any medicine and resumed his 
 riding exercises. Again the symptoms recurred, and 
 this time there was definite effusion into the hip- 
 joint. The anti -rheumatic remedies once more 
 relieved his pain, though the effusion lasted for about 
 a week. For months off and on this patient suffered 
 irom similar relapses whenever he over-exercised 
 himself, and it was not until he had been prevailed 
 upon to visit one of the well-known spas and to 
 undergo a definite course of treatment that he finally 
 lost all constitutional symptoms. This is but a type 
 of innumerable instances of local injuries being 
 influenced and exaggerated by some constitutional 
 defect. 
 
 When there is a gouty history it is the usual 
 custom to exhibit the iodides internally, and some- 
 times even colchicum, while at the same time local 
 remedies are applied. Vasogen-iodine is an excellent 
 local application ; it produces but little irritation 
 and is a convenient substance for ' rubbing in '. 
 With syphilitic subjects small doses of mercury pre- 
 scribed in pill are to be preferred to the continued 
 administration of the iodides. 
 
 The treatment of haemophilia is absolute rest 
 coupled with the internal administration of calcium 
 
SPRAINS CONSIDERED GENERALLY 31 
 
 lactate. Ergot would seem to exert but little 
 influence. Fortunately these cases are extremely 
 rare; nevertheless, the surgeon must not lose sight 
 of them. 
 
 Tuberculosis as a sequela and complication will 
 be referred to later. A large, superficially situated 
 hsematoma, especially if it is some distance from a 
 joint, is best treated by a free incision, removal of all 
 clots, and immediate suture. With aseptic methods 
 drainage is not only unnecessary but usually inad- 
 visable. Elastic pressure may with advantage be 
 applied over the absorbable antiseptic dressing. 
 When the skin wound is healed, which is usual in 
 about ten days or earlier, and when the stitches 
 have all been removed, massage may be begun. 
 The scar should be avoided during the manipula- 
 tion, and the movements confined for the most part 
 to the peripheral regions at first. Extensive collec- 
 tions of blood are to be met with in the loose parts 
 and spaces of the body, as in the upper thigh and 
 buttock, in the axilla, sheaths of the rectus abdo- 
 minis and psoas and iliacus muscles. Such large 
 collections are usually the result of arterial bleeding, 
 and are found only in situations where a vessel of fair 
 size may be torn. When muscles are torn across, 
 the bleeding is mostly venous, on rarer occasions 
 arterial. A branch of the deep epigastric artery is 
 sometimes wounded when the rectus abdominis 
 muscle is torn across as the result of violent muscular 
 strain, or from blows upon the lower abdomen. 
 
 Of TH8 
 
 UNIVERSITY 
 
 OF 
 
32 SPRAINS CONSIDERED GENERALLY 
 
 Tension in Joints after Sprains 
 
 The ' tension in joints ' of writers is the condition 
 which sometimes follows immediately an injury to 
 a joint, or occurs at some later period, it may be 
 hours, days, or even weeks after. In such a con- 
 dition we find the capsule of the joint distended, it 
 may be to its fullest capacity, by a fluid effusion. 
 When this is early in its appearance, immediate, in 
 fact, it must be regarded as the result of haemorrhage ; 
 when coming on gradually, creeping on, as it were, 
 it is the consequence of secondary and inflammatory 
 processes. Inflammation may result from renewed 
 local injury or from any of the constitutional states 
 above enumerated, such as gout or rheumatism. 
 Local heat is invariably a symptom of tension ; it 
 may be marked and easily to be detected with the 
 aid of the hand, or so slight as to be hardly discernible 
 by touch. The more rapid the incidence of the 
 swelling, as a rule, the more distinct are the evidences 
 of heat locally. Pain, often constant, readily in- 
 creased by any movement, whether passive or 
 active, is complained of. This is often severe, so 
 severe, indeed, as to give rise to symptoms of consti- 
 tutional disturbance such as sleeplessness, loss of 
 appetite and general irritability. In the most severe 
 cases, where even a bandage is tolerated with diffi- 
 culty, one of two lines of local treatment is adopted 
 by the writer. Where there is no important consti- 
 tutional contra-indication existing, such as marked 
 or severe cardiac or renal disease (glycosuria or 
 chronic albuminuria), and where there is no suspicion 
 of haemophilia, much relief from pain will result if,. 
 
SPRAINS CONSIDERED GENERALLY 33 
 
 with the aid of an anaesthetic, the joint is aspirated. 
 All that is required in the majority of cases is that 
 an ounce or at most two ounces of serum be with- 
 drawn from the cavity. The relief afforded is as 
 quickly experienced as is the cure of toothache when 
 the tooth is extracted. There is no necessity for 
 drawing off all or most of the contents of the joint ; 
 indeed, it has been found that recurrences are more 
 usual after the full removal than after partial. The 
 requirements can be sufficiently met if only as much 
 effusion is withdrawn as will diminish the tension 
 and relieve the pain so that elastic pressure may be 
 applied and tolerated with some degree of comfort. 
 Not only does aspiration relieve pain, but it initiates 
 the processes of absorption. The blood-vessels and 
 lymphatics around a joint that is completely dis- 
 tended are overstretched or mechanically blocked, 
 so that either absorption ceases altogether or goes 
 on at a disadvantage. The withdrawal of the fluid 
 with the relief of tension in the joint, assisted by 
 the elastic compression applied to the tissues around 
 the joint, give such assistance as is necessary for dis- 
 placing the fluid towards the general circulation. In 
 this way the continual absorption of extravasated 
 materials is insured. Such is the theory upon which 
 the practice is based. 
 
 When a patient objects to aspiration or any other 
 form of operation, or when there are other contra- 
 indications, the symptoms are often materially and 
 readily relieved by submitting the joint to dry heat 
 in a bath. This may be carried out by means of 
 a radiant heat apparatus. In a certain proportion 
 of cases, although not a large one, this method is 
 
 WHITELOCKE J) 
 
34 SPRAINS CONSIDERED GENERALLY 
 
 useful, and may even work like a charm ; yet, 
 occasionally, it must be admitted, that this plan of 
 treatment is absolutely useless and fails entirely. 
 When dry heat is unobtainable, or where it has been 
 given a fair trial and has not come up to expecta- 
 tions, hot fomentations with laudanum or lead 
 lotion may have a soothing effect. As soon as it is 
 noticed that the tension is diminishing, either of 
 itself or as the result of treatment, elastic pressure, 
 followed by or combined with massage, may be com- 
 menced and continued until all or most of the fluid 
 has disappeared. Movements, voluntary and passive, 
 must be withheld until tension has quite or almost 
 gone, and so long as any pain or local temperature 
 remain. In recurrent cases, and in those in which 
 the integrity of the joint is at stake owing to chronic 
 distension of the capsule, and where considerable 
 wasting of the muscles exists and seems to be in- 
 creasing, arthrotomy and digital exploration of the 
 joint itself may be necessary and even advisable. 
 No open operation should, however, be hghtly under- 
 taken, especially where the knee-joint is concerned. 
 The writer has on several occasions found that the 
 opening of a knee-joint is the only satisfactory means 
 of dealing with faulty adhesions within its capsule. 
 It should only be as a last resource and when other 
 means have failed, and when it is considered that the 
 joint must otherwise become permanently damaged, 
 that arthrotomy and temporary drainage is recom- 
 mended. The surgeon must be, moreover, one who 
 is fully alive to the risks of opening the knee-joint 
 and one who has the fullest confidence in the methods 
 of his surgical technique, for unless absolute cleanli- 
 
SPRAINS CONSIDERED GENERALLY 35 
 
 ness and thorough asepsis can be guaranteed, 
 arthrotomy should never be practised. More will be 
 Avritten in a later chapter as to the details of arthro- 
 tomy as advocated and practised by the writer 
 (see p. 154). 
 
 Sprains complicated with Injury to the 
 Nerves 
 
 Of the complications of sprains this is one of the 
 most important, and requires special attention as 
 regards diagnosis and treatment. In the laceration 
 of muscles, as well as in the overstretching of the 
 ligaments of joints, branches of nerves are liable to 
 injury. Even a gross lesion in a nerve may escape 
 the notice of the surgeon when making his first 
 examination, unless he carefully looks for it. It is 
 often only when imperfect recovery has taken place, 
 and when the reasons for this are sought, that 
 a surgeon begins to suspect that there may have been 
 some injury to a nerve. When pain radiates along 
 the branches of a large trunk like the great sciatic, 
 or where there is marked and distinct paralysis, 
 a surgeon's attention is at once arrested ; but when 
 the nerves, coursing as they do between the abdo- 
 minal muscles and between the ribs, are injured, as 
 in sprains of the sacro-lumbalis, psoas, and other 
 muscles of the trunk, they may readily escape his 
 notice; nor is this surprising when we consider the 
 predominance of the other symptoms in all cases of 
 severe sprain. Numbness or tingling in some part 
 remote from the injury is of frequent occurrence, and 
 would seem to indicate an overstretching. Such 
 symptoms are met with when the head of a dis- 
 
 'D 2 
 
36 SPRAINS CONSIDERED GENERALLY 
 
 located bone stretches or presses upon a nerve. 
 Numbness usually passes off in from twenty-four to 
 thirty-six hours, or as soon as the pressure is relieved 
 or the stretching force relaxed. Should the symptoms 
 persist, massage may be tried and kept up until 
 distinct relief is afforded. When, on the other hand, 
 the pain radiates along the course of a particular 
 nerve or group of nerves, absolute and complete 
 rest becomes imperative. Massage and movements 
 do positive harm, and herein lies the inherent diffi- 
 culty in treatment. We have seen that in simple 
 sprains and strains, movement and massage are 
 advocated while fixity is deprecated. In no class 
 of complicated cases does the rule-of-thumb move- 
 ment and exercises recommended by the bone-setter 
 do more harm than in this. The limb or joint must 
 be given absolute rest, though not necessarily placed 
 in a splint, until the pain has completely disappeared 
 or is rapidly subsiding. Then very gentle friction 
 massage may be cautiously tried. If the pain is in 
 the least degree increased after exercise it should 
 be forbidden. A good alternative plan to the use of 
 massage is that of bandaging the whole limb or part 
 of the body, as the case may be, with a bandage of 
 stout elastic webbing. By this device it is possible 
 to partially deplete a limb or other part of its 
 blood. When such a bandage is retained for say 
 five minutes or less, and then suddenly and rapidly 
 removed, local flushing results. In this way fresh 
 arterial blood is brought to the injured part, while 
 on the re-application of the bandage the vitiated 
 materials are removed by compression and hurried 
 into the general circulation. The advantage which 
 
SPRAINS CONSIDERED GENERALLY 37 
 
 accrues from this practice is that the general nutri- 
 tion of the nerve-endings is improved. This is 
 especially true of the treatment of chronic cases, and 
 in this particular class it may be necessary to remove 
 and re-apply the bandage two or more times in 
 twenty-four hours. At first, progress is slow, but 
 after a few days, as a rule, the pain will gradually 
 subside and disappear. The local neuritis seems to 
 be remarkably influenced by the increased oxygena- 
 tion, just as the flushing caused by taking a glass 
 of wine will, in many persons, rapidly dispel an 
 attack of acute supra-orbital or facial neuralgia. 
 The repeated and alternating depletion and flushing 
 of the injured tissues stimulates the local circulation. 
 Whatever the true explanation may be, the fact 
 remains that the effect is good and that it is nearly 
 always speedily beneficial. In the more chronic 
 forms, those resulting from neglected treatment in 
 the first instance, electricity in the static form has 
 been found useful, while massage may or may not 
 succeed. Blistering, and even the point of the actual 
 cautery have been employed on many occasions to 
 counteract the intensity of the pain as it courses 
 along the nerve-trunk. Opiates should be avoided 
 because these cases often last a long time, and the 
 continued use of drugs is baneful and can only at 
 best give but temporary relief. One of the most 
 rapid and obstinate forms of the wasting of muscles 
 results from gross nerve lesion. It is more rapid, 
 more complete, and more lasting than any of the 
 forms that result from mere disuse. 
 
38 SPRAINS CONSIDERED GENERALLY 
 
 Sprains with Fractures and ' Fracture- 
 Sprains ' 
 
 The treatment of this class differs from that of 
 a simple sprain in certain particulars. Thus, where 
 small fragments are detached, pulled away with the 
 ligaments or tendons, it becomes necessary to aim 
 at giving sufficient rest to enable if possible bony 
 union to take place. Elastic pressure, applied in 
 the same way as for simple sprain, is useful, for, when 
 employed, a modicum of rest is assured without the 
 necessity of making use of actual splints. Passive 
 movements, carefully made, may be begun from the 
 very earliest, but any forcible voluntary efforts which 
 would tend to separate the fragments must be 
 strictly prohibited. Massage may be used all the 
 time, but cautiously at first. Exercises are of value 
 late in the case. Where there is fracture without 
 separation, as in fissures in the lower end of the 
 fibula or tibia, the meta-carpals or small bones of 
 the carpus, and where there is but slight effusion, 
 strapping as for an ordinary strain is convenient. 
 Passive movements are more helpful on the whole 
 than active ; the latter, however, may be allowed, 
 but only to a limited extent and providing no strain 
 is directly put upon the region of the fracture. The 
 patient may, in the case of the smaller joints, be 
 allowed to flex or extend the joints fully without 
 using much force. Exercises should be encouraged 
 after the bones have had time to unite, but not 
 before. Unless these rules are strictly adhered to, 
 imperfect recovery will result, for faulty or incom- 
 plete union must follow whenever forcible voluntary 
 
SPRAINS CONSIDERED GENERALLY 39 
 
 movements are permitted in the early stages. The 
 main difference between simple sprains and those 
 complicated by fracture is that, in the former, 
 voluntary or active movements are permitted and 
 
 Fig. 6. Radiogram of a fracture of the olecranon without displacement, 
 at first regarded as a sprain. Massage and early movements in such 
 a case are absolutely contra-indicated. 
 
 encouraged from the very earliest stages, and are 
 essential to a speedy recovery ; in the latter they 
 must be secondary to passive movements and allowed 
 only in the later stages. Massage is of equal service 
 to both classes, and, speaking generally, may be 
 begun early. In simple sprains passive movements 
 
40 SPRAINS CONSIDERED GENERALLY 
 
 are of secondary importance, while in those compli- 
 cated with fracture they are of greater service than 
 are voluntary exercises, and especially is this true 
 of the early treatment ; exercises are helpful in both 
 classes in the later stages. 
 
 Many sprains with fracture produce stiffness, for 
 the simple reason that they are not at first recog- 
 nized and are treated by the so-called rational 
 treatment of simple sprains. Treatment by massage 
 and early movement by exercises is unsuitable where 
 they are concerned. It is of the utmost importance 
 that in all cases of unusual severity, and in doubtful 
 cases, an X-ray photograph should be taken from 
 different aspects. This affords our best means of 
 diagnosis, upon which alone must depend the success 
 or otherwise of treatment, for without a correct 
 diagnosis much unnecessary suffering will be experi- 
 enced and considerable time lost. 
 
CHAPTER III 
 
 SEQUEL.^ OF SPRAINS 
 
 Many disabilities result from the faulty or careless 
 management of sprains, while some cannot in any 
 way be ascribed to the fault of the surgeon. They 
 arrange themselves into two categories : the controll- 
 able and the uncontrollable. Of the former group 
 there are many, of the latter, few. 
 
 Of the preventable forms, we meet with : 
 
 (1) Stiff joints and painful joints. 
 
 (2) Atrophy and wasting of muscles acting on 
 joints. 
 
 (3) Recurring or relapsing synovitis in joints. 
 
 (4) A relaxed condition of joints known as ' wobbly 
 joint ' or ' weak joint ' ; the opposite condition to 
 Group 1. 
 
 (5) Persistent pain in a joint. 
 
 (6) A crippled or deformed joint. 
 
 (7) Improperly united muscles and tendons. 
 
 (8) Ankylosis. 
 
 Stiffness in joints as a result of sprain is almost 
 invariably due to prolonged fixation in spUnts or 
 other rigid apparatus, assisted by the prohibition of 
 or delay in beginning movements during the treat- 
 ment. For some reason, not altogether independent 
 of textbook teaching in the past, it has been the 
 habit to regard so-called rest as a primary and all- 
 pervading essential in the treatment or management 
 
42 SEQUELS OF SPRAINS 
 
 of any injury. The treatment of sprains, perhaps, 
 of all injuries has suffered most from this doctrine. 
 That a joint, designed and constructed as it is by 
 nature for movement, should be dealt with in pre- 
 cisely the same way when it suffers violence as a 
 bone arranged and planned for a purpose the very 
 opposite, seems strange ; yet, strange as it may 
 seem, it is only too true that even at the present day 
 there are surgeons who treat sprained joints in pre- 
 cisely the same way as they do fractures. Nothing 
 can be more harmful to the normal movements of a 
 joint than a prolonged and constant use of splints, 
 and if for any reason a splint should be considered 
 advisable, the same should be removed at least once 
 a day, so that movements in the joints may be 
 allowed. The writer, for over eighteen years, has 
 never had occasion to use a splint, and he firmly 
 believes that sprains will do better if left alone 
 without any special treatment than when they are 
 subjected to prolonged fixation. The bugbears 
 'inflammation' and the 'dread of tuberculosis', 
 would seem to haunt the minds of some as if they 
 were veritable demons. One need hardly point out 
 that in the absence of local temperature such fears 
 are ungrounded. 
 
 Painful joints and stiff joints. Joints remain 
 painful and stiff as the result of immobilization, 
 whereby the surrounding tissues become matted 
 together ; the nerve-endings are pressed upon by 
 exudation products which are unabsorbed ; and are 
 injured by an impeded and sluggish blood-supply 
 deficient in oxygen ; circumstances which all lead up 
 to an impaired nutrition. 
 
SEQUELiE OF SPRAINS 43 
 
 Atrophy and wasting of muscles acting on joints. 
 This results from two main causes : (a) a definite 
 injury to the nerve-supply, and (b) disuse, often 
 associated with the long-continued application of 
 splints and other apparatus during the course of 
 treatment. 
 
 (a) Examples of the former class are the changes 
 observable in the distal portion of a ruptured tendo- 
 achillis which has remained ununited. The distal 
 part of the tendon, cut off from the nerve-supply to 
 the muscle fibres on the proximal side, atrophies, 
 shrivels, and takes on the consistence and appearance 
 of a piece of wash-leather. Again, when the adductor 
 longus muscle becomes torn from its pelvic attach- 
 ment, in a case of so-called 'rider's sprain', it is no 
 uncommon circumstance to find the muscle almost 
 completely wasted away. The rapid wasting in the 
 deltoid, resulting from overstrain or partial rupture, 
 is doubtless due to nervous influences — possibly the 
 cutting off of the nerve-supply. 
 
 (b) Examples of wasting from disuse, arising as a 
 consequence of unduly prolonged fixation and tardy 
 resort to movements and exercises in the treatment 
 of a large joint like the knee or shoulder, are of too 
 frequent occurrence ; and it cannot be emphasized 
 too often, in connexion with this, even at the risk of 
 being tedious, that the wasting of muscles begins 
 almost immediately after an injury, and that passive 
 movements by themselves have little or no bene- 
 ficial or preventive influence. Voluntary movements, 
 however slight in the beginning, gradually increased 
 as they are better tolerated, assisted by the skilful 
 application of massage, will alone retard or prevent 
 
44 SEQUELS OF SPRAINS 
 
 this form of atrophy. Later on, properly regulated 
 exercises, planned so as to work against resistance, 
 do much to promote complete restoration to useful- 
 ness. Voluntary movements and massage should 
 be persevered with in both forms of wasting, but the 
 surgeon must be prepared for disappointment in a 
 certain number of cases, notably those in which a 
 gross nerve lesion is the primary cause. 
 
 Recurring and relapsing synovitis. In a certain 
 number of severe articular sprains, in which there 
 has been considerable tearing of the external liga- 
 ments, the capsule and synovial membrane, the 
 effusion, which at first was copious, clears up readily 
 and satisfactorily under rational treatment, but as 
 soon as the patient begins to walk or move the joint 
 it again refills. The tension may be high or moderate, 
 and there may be some local increase in temperature. 
 When elastic pressure is applied the effusion is 
 absorbed in a very short time, but relapse after 
 relapse, recurrence after recurrence, follows, and 
 lead to a general relaxation of all the ligaments. 
 This troublesome condition is generally due to the 
 presence of an adhesion or adhesions within the 
 joint. The simple folding of a small and insignificant 
 portion of the synovial membrane upon itself, or 
 some irregular attachment by a tag of the capsular 
 ligament which has become curled inward towards 
 the articular surfaces of the bone, are sufficient to 
 produce synovitis whenever dragged upon during the 
 ordinary movements of the joint. Such a state of 
 affairs is best prevented by the routine advocated in 
 a former chapter— that of putting every severely 
 sprained joint through its normal movements before 
 
SEQUELS OF SPRAINS 
 
 45 
 
 any treatment whatever is commenced, an anaesthetic 
 being used if necessary. When adhesions have 
 formed, they are best remedied by forcible move- 
 ments under an anaesthetic, the movements being 
 
 Fig. 7. To illustrate the scar left from the operations. for exploratory 
 arthrotomy and removal of internal semilunar cartilage. From a case 
 three months after the operation for removal of synovial fringes. 
 
 followed by the usual course adopted for the treat- 
 ment of recent sprains. If the effusion should keep 
 on recurring in spite of this, it is well to perform an 
 exploratory arthrotomy to remove any band or 
 adhesion existing within the joint. The knee is the 
 joint which is most prone to these recurrent attacks. 
 
46 SEQUELS OF SPRAINS 
 
 In some of the most obstinate cases the condition is 
 due to the presence of thickened synovial fringes. 
 The accompanying photograph shows the usual 
 incision employed by the writer whenever he makes 
 a digital exploration of the knee-joint. It extends in 
 a slightly curved direction over the inner side of the 
 joint for about four inches, having its centre opposite 
 the internal semilunar cartilage. When the skin and 
 fasciae have been divided, the capsule comes well 
 into view. This, in its turn, is divided parallel with 
 the skin incision ; the joint is then opened. By 
 everting the outer edge of the wound, the under 
 surface of the patella, with the infra-patella pad of 
 tissue (ligamenta mucosa et alaria) may be freely 
 exposed to view. The finger of a gloved hand may 
 now be inserted and a careful exploration made of 
 every corner of the articulation. The synovial 
 membrane, in these cases, is often of a pale yellowish 
 fine-dotted appearance, slightly granular on its 
 visceral surface. The secretion varies in different 
 individuals and at different stages, according as to 
 whether the effusion is recent or late. While at 
 times it is liquid and slightly viscid, at others it may 
 be of the consistence and appearance of boiled sago. 
 If the synovial membrane is examined microscopi- 
 cally it presents the usual characteristics of a catarrhal 
 inflammation. Adhesions, however small, should be 
 clipped away with scissors, and any hypertrophied 
 portions of synovial membrane carefully removed. 
 It is imperative that all bleeding points should be 
 carefully attended to ; dry swabbing is much prefer- 
 able to douching or irrigation. The writer has 
 almost entirely abandoned the practice of douching 
 
SEQUEL.^ OF SPRAINS 
 
 47 
 
48 SEQUELS OF SPRAINS 
 
 out joints, and sponges with dry swabbing instead. 
 A gauze drain is inserted at the middle of the capsular 
 wound, and the rest of the capsule is brought together 
 with catgut sutures ; the skin wound, with silk- 
 worm gut. A bicyanide gauze dressing, covered by 
 a thick pad of salicylic or boracic wool is then applied, 
 but no splint. The drain should be removed in 
 twenty-four hours, the wound then sealed and left 
 undressed for nine days, providing the temperature 
 remains satisfactory. The accompanying tempera- 
 ture chart is characteristic of exploratory arthro- 
 tomy. There is usually a rise of temperature for the 
 first two days ; this should subside on the third or 
 at latest on the fourth day. Gentle passive move- 
 ment may be tried at the first dressing, twenty-four 
 hours after the operation ; massage and voluntary 
 movements are best postponed until after the re- 
 moval of the stitches, usually from the eighth to 
 the ninth day, and they must be both continued 
 until the joint becomes firm and strong and the 
 tendency to muscular atrophy and to recurrent 
 effusion has passed. 
 
 A generally relaxed condition in a joint, popularly 
 known as * wobbly joint' or ^weak joint'. The so- 
 called ' wobbly joint ' is the result of muscular atrophy 
 in the proximal muscles of a sprained joint. The 
 accompanying photograph, taken from a case in 
 which fixation in plaster of Paris for the greater part 
 of six months was permitted, on the assumption that 
 the slight elevation of local temperature indicated 
 early tuberculosis, is typical and characteristic of the 
 condition. The subject was a young military officer 
 who, while playing at football, twisted his left knee. 
 
SEQUELS OF SPRAINS 
 
 49 
 
 The pain was confined to the outer and posterior region 
 of the joint. At the time, no locking or impaired 
 mobility was experienced, and he was immediately 
 
 Fig. 8. Photograph of both thighs. The left knee shows deformity 
 from imreduced semilunar cartilage (internal). The Hmb had been retained 
 for nearly six months in plaster splints. Note marked atrophy of the 
 muscles of the thigh on proximal side of the joint, also semiflexure of the 
 knee, with hypertrophy of the muscles of calf. This is somewhat charac- 
 teristic of knees long retained in splints without movement. Such a joint 
 readily fills when exercised, and illustrates the so-called ' weak ' or 
 ' wobbly joint '. 
 
 able to walk. Some swelling of the joint was noticed 
 next day when a bandage which had been applied 
 was removed. He remained on the sofa, but being 
 in India and many miles away from any medical 
 
 WHITELOCKE -p 
 
50 SEQUELS OF SPRAINS 
 
 attendant he began to walk about in a few days. 
 At the end of ten days, the ' pain and swelling having 
 quite subsided', he again played football. Pain 
 quickly returned, and this time was referred to the 
 centre of the back of the knee. He experienced no 
 sensation of anything giving or tearing, and although 
 he could bend and straighten the joint freely it 
 rapidly swelled up, as he described it, ' to an enor- 
 mous size.' Surgical advice was now sought, but 
 not obtained until thirty-six hours later. Rest in 
 bed, evaporating lotions, and the usual textbook 
 routine was gone through ; the swelling gradually 
 subsided, and splints were used from the first. 
 Three weeks later he was allowed to walk, with the 
 limb encased in a moulded splint, but the joint at 
 that time was weak, stiff and painful. As he did 
 not seem to prosper, and as the joint swelled when- 
 ever he stood erect, and was hotter than its neighbour, 
 his medical attendant thought that tuberculosis was 
 probably beginning. For the next five months the 
 limb was kept fixed in a plaster casement. These 
 details have been supplied here as illustrative of the 
 line of treatment so often adopted, and with such 
 untoward results. It is important to notice the 
 more marked atrophy of the proximal muscles of the 
 thigh as compared with those in the leg or distal to 
 the joint. In these relaxed states of the ligaments 
 the recurrent synovitis in most cases is a passive one ; 
 the joint filling simply from loss of support to its 
 capsule, secondary to wasting and enf eeblement in 
 the muscles which control its movement. 
 
 It is of the utmost importance that it should be 
 clearly understood that the swelling is^ secondary to. 
 
SEQUELS OF SPRAINS 51 
 
 and dependent on, the wasting of the muscles, and 
 that treatment should be directed towards rectifying 
 the enfeebled condition of the controlling muscles 
 rather than to the joint itself. Local treatment, 
 such as blistering and other forms of counter-irrita- 
 tion, are helpful only to a limited degree and will not 
 cure the condition. Massage and movements, both 
 active and passive, and those against resistance, 
 must be strenuously persisted in until such time as 
 the tone of the capsular ligament is restored or at 
 any rate materially improved. 
 
 The improvement will be in proportion to the 
 amount of perseverance shown in carrying out the 
 exercises, and the degree of recovery to the length 
 of time that has been saved or lost before rational 
 treatment was begun. It may take months before 
 the strength of the limb is restored, and in some, 
 fortunately a small percentage of cases, complete 
 recovery must not be expected. Especially is this 
 true when, in addition to the mismanagement by 
 prolonged fixation, there has been extensive lacera- 
 tion of the tendons and aponeuroses in and around 
 the joint. 
 
 Persistent pain in a joint is characteristic of gross 
 injury to nerves. It is generally referred along 
 the line of a particular nerve or group of nerves, 
 notably after injury to the largest joints, the hip, 
 knee, shoulder and elbow. In some cases it appears 
 to be of the nature of neuritis, occasioned by the 
 bruising of the nerves themselves, or to adhesions of 
 their sheaths to the surrounding parts analogous to 
 the pain experienced when a nerve is caught in 
 callus at or near the seat of a fracture.. The normal 
 
 E 2 
 
52 
 
 SEQUELS OF SPRAINS 
 
 and healthy nutrition of the nerve becomes altered. 
 In a certain proportion, the pain or neuralgia is 
 caused or intensified by gout or rheumatism ; as a 
 rule these cases ai^ readily improved by the appro- 
 
 FiG. 9. False joint at right hip, the result of treatment for supposed 
 sprain by bone-setter. The neck of the bone has been worn away by 
 continued movements and exercises, and the patient permanently lamed 
 and left with a deformed hip. 
 
SEQUELS OF SPRAINS 53 
 
 priate remedies for these constitutional diseases. 
 The pain is generally worse at night, and in a few 
 exceptional cases has been so severe as to necessitate 
 the exhibition of opiates. Friction massage at the 
 hands of an experienced masseur will generally serve 
 
 Fig. 10. Radiogram of fracture of the first phalanx of little finger of 
 a child, treated previously as sprain. Note the absence of displacement 
 of the fragments. The joints, both above and below, were full of fluid 
 and masked the symptoms of fracture. An injury at the junction of the 
 upper epiphysis with the shaft of the bone led to permanent deformity. 
 
 to diminish its intensity, so that strong drugs are 
 rarely needed. Aspirin in full doses will in many 
 cases reUeve the attacks of aching pain, and in some 
 remove them altogether. 
 
 The crippled and deformed joint. ^ Deformities 
 formerly were considered to be the result of osteo- 
 
54 SEQUELiE OF SPRAINS 
 
 arthritic changes, but are now known, through the 
 experience gained by radiography, to be frequently 
 owing to the separation of the epiphyses or even to 
 fractures. The accompanying photographs bear out 
 this fact. Deformities may be met with in the large 
 as well as the small joints ; the flattening out of the 
 
 Fig. 11. New false joint in lower third of humerus, the result of 
 moving the limb to prevent stiffness at the elbow. Note ball-and-socket 
 arrangement of false joint and development of a styloid-Uke process 
 which had become detached by a second accident a year later. To 
 illustrate the dangers of indiscriminate movements in the treatment of 
 joints. 
 
 hip with atrophy of the gluteal muscles, so often 
 represented in the older textbooks as resulting from 
 a fall with bruising, is typical. At one time this 
 condition was ascribed to some subtle change in the 
 neck of the femur, whereas we now know that it 
 
SEQUEL.^ OF SPRAINS 55 
 
 results from a fracture through the neck of the bone. 
 The genu- valgum or genu-varum which follow upon 
 a sprained knee in a growing youth are frequently 
 the result of fracture through a condyle of the femur, 
 or to partial separation of or severe bruising over the 
 growing epiphysis, either at the lower end of the 
 femur, or upper extremity of the tibia. Examples 
 are more frequently met with at the elbow ; here, as 
 the result of some slight strain in early life, a per- 
 manent deflection of the forearm outward with an 
 apparent lengthening of the inner condyle may be 
 seen in the adult. In the fingers, fractures of the 
 phalanges are by no means uncommon ; wicket- 
 keepers are specially liable. Without the X-rays 
 it is next to impossible in most cases to make a 
 correct diagnosis ; a wise surgeon will therefore 
 do well to bring them to his aid whenever it is 
 practicable. 
 
 Improperly united muscles or tendons. As a 
 consequence of laceration of important muscles like 
 those of the thigh, the adductors, as well as the 
 extensors and flexors of the knee, wide separation is 
 apt to take place between the torn ends. Unless in 
 the course of treatment the fibres are brought 
 together, so that more or less firm fibrous union 
 takes place, the scar is apt to stretch at a later period 
 and give rise to insecurity and disfigurement. The 
 proximal portion has always a tendency to be 
 drawn away from the seat of injury. It is fortunate 
 that the other muscles of the same group will as a 
 rule develop and increase in size proportionately to 
 make up somewhat for the deficiency and actual loss 
 of power in the torn muscle. It has been found. 
 
56 SEQUEL.E OF SPRAINS 
 
 however, that rupture of the rectus femoris and 
 portions of the deltoid muscle have seriously influ- 
 enced the stability of the knee- and shoulder- joint 
 respectively. It is important, therefore, that close 
 and complete apposition should be secured from the 
 very first, even if it is necessary to obtain the union 
 by means of an open operation. No undue strain 
 should be permitted until the united parts have had 
 full time to become firm. 
 
 Ankylosis may result from severe sprains. Fortu- 
 nately, the condition is an exceedingly rare one, if we 
 except those cases of stiff -joint which at first sight 
 similate true bony ankylosis but which readily yield 
 to ' breaking-down ' under an anaesthetic. Such a 
 case usually originates from a sprain with fracture, 
 the true nature of which was unrecognized and 
 treated by excessive and ill-advised movements. The 
 enforced movement gives rise to increased formation 
 of callus in the neighbourhood of the articular 
 surfaces, which not only tends to mechanical locking, 
 but affords opportunity for new and extensive 
 adhesions to form. 
 
 Unavoidable Sequels 
 
 These permanent and remote consequences of 
 sprain are entirely beyond the control of the surgeon, 
 but are nevertheless of much interest to him in so 
 far as they influence, in the main, his prognosis. 
 They consist of : — 
 
 1. Local paresis or paralysis. 
 
 2. Ossifying myositis, as concerns sprains in 
 muscles, and 
 
SEQUELS OF SPRAINS 57 
 
 3. Osteo-arthritis in relation to articular strain. 
 
 4. Loose bodies in the joints. 
 
 Localized palsy and paresis result for the most 
 part from overstretching or laceration of nerves or 
 their branches ; but it is rarely met with. When 
 
 wwK^»5»»fm^'>^^ 
 
 Fig. 12. Ossifying myositis in muscles of thigh, the result of a blow. 
 Note the crescent-shaped mass attached to the middle of the shaft of the 
 femur anteriorly. From an X-ray photograph taken nine weeks after the 
 accident. 
 
 the torn ends of a muscle are widely separated, as 
 the consequence of sudden violence, the nerve of 
 supply may be damaged. .Repair, in the generality 
 of instances, results from treatment, and cases of 
 permanent defect are rare ; when they do occur they 
 are unavoidable. Friction and kneading massage 
 
58 SEQUELS OF SPRAINS 
 
 may do good and will need to be carried on for a 
 considerable time. Electrical stimulation, in certain 
 cases, may also assist. 
 
 Ossifying myositis is also rare. It is almost in- 
 variably met with in the large muscles and in those 
 
 Fig. 13. Myositis ossificans in extensor muscles of the thigh, result 
 of a kick by a horse. Note the intimate connexion of the mass with the 
 anterior surface of the femur. From an X-ray photograph taken sixteen 
 weeks after the accident. 
 
 whose fibres take origin directly from some rough 
 bony ridge, or which are directly attached to the 
 periosteum without the intervention of much tendi- 
 nous material. The writer believes that in all such 
 cases portions of the periosteum become detached 
 with the muscle at the time of injury and are pulled 
 away from the bone by the contraction of the 
 muscular fibres. The detached periosteum soon 
 
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60 SEQUELS OF SPRAINS 
 
 becomes enveloped in the subsequent extravasation, 
 which for the most part consists of blood-clot, for 
 the vessels of the periosteum bleed profusely when- 
 ever they are torn. The osteo-blasts, which are 
 normally numerous between the deeper layer of the 
 periosteum and the bone, stimulated in their new 
 situation partly by the increased blood around 
 them, partly by the contractions of the muscle, 
 and perhaps by movements of massage during the 
 treatment, proliferate and proceed to the deposition 
 of new bone. This theory is based upon the follow- 
 ing observation. The accompanying X-ray photo- 
 graphs were taken from two different cases ; in the 
 one (Fig. 13) the bony growth is seen projecting from 
 the anterior surface of the femur into the quadratus 
 extensor muscle. This resulted from a direct blow, 
 the kick of a horse, in an adult man. It will be noticed, 
 in comparing it with the next picture (Fig. 14), that 
 an ossification has resulted in the same muscle and 
 at about the same situation in the thigh. The 
 second picture represents, however, the result of a 
 strain of the muscle produced while the patient, a 
 youth, was playing at football. In this case, what 
 happened was probably that the periosteum was 
 stripped from the shaft of the bone, owing to a 
 sudden and violent contraction of the crureus muscle, 
 and is therefore an example of indirect violence. 
 The new growth of bone in this case lies in the belly 
 of the muscle, parallel with, but separated from, the 
 femur ; it is seen to be laminated. The pathological 
 condition in this particular instance is similar to 
 that pertaining to callus-formation at the seat of a 
 fracture. The periosteum being torn, the osteo- 
 
SEQUELS OF SPRAINS 61 
 
 blasts are set free into the blood-clot which surrounds 
 the fragments of bone, and stimulated by the move- 
 ments of the broken fragments, rapidly proliferate 
 and produce new bone. 
 
 On one occasion the writer was able to verify the 
 
 FiQ. 15, Photograph of thigh showing a swelhng anteriorly about the 
 middle, due to ossifying myositis in the extensor group. The result of 
 a football strain. 
 
 existence of torn periosteum with its deposition of 
 new bone, in a case of extensive hsematoma in the 
 caH. The patient, a gentleman aged twenty-two, 
 was thrown from his horse while hunting, and being 
 caught in the stirrup was dragged. In addition to 
 other injuries he tore away portions of his soleus 
 muscle from its origin at the oblique line of the tibia. 
 
62 SEQUELS OF SPRAINS 
 
 When, ten days after the injury, an incision was 
 made into the enormous sweUing that resulted, for 
 the rehef of the much-impeded circulation in the 
 foot, and after the clots had been removed, right 
 along the whole length of the muscular detachment 
 were to be seen and felt signs of commencing ossifi- 
 cation. The detached portions of the periosteum 
 still adhered to the muscle fibres and were rough and 
 gritty to the touch. Ossification had already begun 
 in the clot which lay between the soleus and the 
 gastrocnemius muscles. 
 
 The detached portions of the periosteum were at 
 the time carefully clipped away with scissors, the 
 clots removed, and the wound closed. In spite of 
 these radical measures, a sharp spicule, owing pro- 
 bably to some detached portion having escaped 
 notice at the time, developed and grew from the 
 oblique line of the tibia. Doubtless, if the other 
 portions had not been removed at the time of the 
 operation, considerable ossifying myositis of the 
 soleus, and probably of the gastrocnemius also, 
 would have resulted. Other examples have been 
 met with by the writer, in the adductor longus and 
 gastrocnemius at their origin, and in the deltoid at 
 its insertion. In ' rider's sprain ' the adductor 
 longus, as well as the pectineus, are usually separated 
 at their pelvic attachments, close to the bone, and 
 in the tearing of these muscles it is probable that the 
 periosteum is separated from the pelvis and that 
 the new bone is deposited among the muscle fibres 
 which arise from it. Ossification in the deltoid and 
 gastrocnemius commences close to their attachments 
 to bony ridges, the one from its insertion, the other 
 
SEQUELS OF SPRAINS 63 
 
 from its origin. Cases have been reported where the 
 condition was described as a ' calcareous deposition ' 
 in the muscles, but in the cases above described, 
 true bone was developed histologically identical with 
 the structure of the cortex of a long bone. 
 
 The ossification of a muscle may be complete, as 
 in the adductor longus, but is generally only partial. 
 The symptoms of ossification develop slowly ; at 
 first there is usually little pain, and all that the 
 patient complains of is that he has a swelling which 
 aches, and that the limb is heavy and the movements 
 in the affected muscles slow and increasingly difficult. 
 The joint controlled by the muscle becomes limited 
 in its movements, and this disability increases as 
 time goes on. The muscles increase in size, are but 
 slightly tender, and become gradually harder. In the 
 later stages and in the worst cases they may become 
 completely rigid, but this is fortunately unusual. 
 
 In a few cases, a certain but limited degree of 
 improvement is noticed, owing partly to a shrinking 
 of the new bone (as shown in photographs taken at 
 different periods of case a) and partly to stretching 
 of the muscles as they are more and more exercised. 
 
 An accurate diagnosis is of the greatest impor- 
 tance. Amputation through the thigh has before 
 now been performed under the impression that the 
 surgeon was dealing with a sarcoma growing from 
 the periosteum of the femur. In one of the cases 
 described before, the early diagnosis was that of 
 tumour, but radiography saved the situation. All 
 doubtful cases should be submitted to the X-rays. 
 
 Preventive measures are of the utmost importance, 
 for other means, short of complete removal of the 
 
64 SEQUELS OF SPRAINS 
 
 muscle with the hope that the neighbouring muscles 
 may develop and take on some of the duties, are of 
 no avail. Where large hsematomata arise, either as 
 the result of direct violence or the consequence of 
 strain, in situations where these ossifications are 
 known to occur, it is a wise plan to operate early. 
 By making a free incision through the muscle into 
 its sheath, and by turning out all clots and removing 
 all torn fibres of periosteum, much may be done to 
 prevent the occurrence. 
 
 When the process has actually commenced, rest 
 is essential ; nothing that will encourage new growth, 
 such as friction massage, should be permitted. 
 Movements, passive as well as active, for the same 
 reason must cease until such time as all tendency 
 to increase has gone by. Later, massage may assist 
 in making the remainder of the muscle more supple, 
 but the main portion of the muscle will for the most 
 part remain permanently useless and the condition 
 unalterable. Complete removal of the growth may 
 be considered when the muscle is completely rigid 
 and useless, especially if it is a source of inconveni- 
 ence. A rigid adductor has been excised to enable 
 the individual to ride. 
 
 Osteo-arthritis. The connexion of these changes 
 with injury is undoubted, but what the exact causal 
 relationship is, remains still a matter of conjecture. 
 Osteo-arthritis is more prone to arise in persons of 
 middle and advanced life than in the young and 
 growing ; it is possible that there are many varieties 
 of the degeneration influenced, or led up to, by 
 different predisposing causes ; some persons would 
 seem to be more liable than others. 
 
SEQUELS OF SPRAINS 65 
 
 The whole subject of the etiology and pathology 
 of osteo-arthritis is so little understood at the 
 present time that a prolonged discussion at this 
 place would serve little purpose ; that it follows not 
 infrequently upon injury, even upon slight injury, 
 is an indisputable fact, and so also that it usually 
 results in those cases in which recurrent effusion of 
 a chronic or relapsing type have been manifest : in 
 fact, just in that particular group of cases that is 
 usually treated with enforced immobility for long 
 periods. No satisfactory means either of preventing 
 or remedying the condition, when it has once been 
 established, are known to the writer, nor is it possible 
 to prognosticate with any certainty that this or that 
 particular injury will or will not be followed 
 by these slowly -forming, yet subtle and progressive 
 changes, so frequently found in and around the 
 bony surfaces of joints. 
 
 Loose bodies in joints may be grouped with 
 the unavoidable sequelae of sprains, and while in 
 many instances, more especially in certain varieties, 
 a traumatic origin may be easily traced, in some the 
 relationship, though strongly suspected, can hardly 
 be said to have been satisfactorily established. 
 There is still much controversy as to the precise 
 etiology and pathology of loose bodies. 
 
 These structures are not infrequently met with, 
 and may be arranged for convenience under two 
 primary headings : 
 
 1. Those introduced by accident into joints from 
 outside, and include such foreign bodies as needles, 
 bullets, and pieces of glass. 
 
 2. Those originating in the joint itself. It is with 
 
 \VHITELOCKE ^ 
 
66 SEQUELS OF SPRAINS 
 
 the second group that we are for the present con- 
 cerned, and under this grouping are two further 
 subdivisions. 
 
 (a) Loose bodies which result from the detach- 
 ment of structures which normally form part of the 
 articulation ; as examples we find detached portions 
 of semilunar cartilages and pieces of articular car- 
 tilage pulled from the subjacent bone by various forms 
 of violence. 
 
 (b) Those derived from the growth or formation 
 of structures which do not form part of the joint in 
 normal circumstances. 
 
 The commoner type of loose body belongs to this 
 second subdivision, and is developed within the 
 joint. 
 
 Three well-known conditions are met with. 
 
 1. The so-called ' rice bodies '. 
 
 2. Detached hypertrophied villous processes of 
 the synovial membrane. 
 
 3. True loose cartilages which, however, by some 
 are said to be due to the development of true hyaline 
 cgirtilage in the synovial fringes and not to any 
 traumatic influence. 
 
 Loose bodies derived from detachment of portions 
 of inter-articular cartilages, and of pieces of articular 
 cartilage or bone within joints will be treated of in 
 a succeeding chapter, when the subject of ' internal 
 derangements of the knee ' come under considera- 
 tion. 
 
 That they are frequently the result of a severe 
 sprain no one will deny. 
 
 Fibrinous loose bodies (corpora oryzoidea) may 
 be mentioned, and though their connexion with 
 
SEQUELS OF SPRAINS 
 
 67 
 
 sprain is a remote one it cannot be denied that on 
 some rare occasions they do unmistakably result 
 from sprain. 
 
 Since these are almost invariably associated with 
 tuberculous changes in synovial membranes, or with 
 
 Fig. 16. Radiogram of a kiiee -joint, showing a partial detachment of 
 a small portion of the rim of the external condyle of the femur. The 
 fragment was loosely attached to the periosteum, but being partially 
 movable produced chronic synovitis. 
 
 such affections as Charcot's disease or arthritis 
 deformans, their consideration need not be enter- 
 tained in the present treatise. They would seem 
 to be sufficiently treated of in the textbooks on 
 general surgery. 
 
 r 2 ^ 
 
68 SEQUELS OF SPRAINS 
 
 Bodies composed of organized connective tissues, 
 such as fat, fibrous tissue, cartilage and bone, 
 may be found growing from synovial membranes 
 in joints which to all intents and purposes appear 
 to be healthy, as well as in those associated with 
 some form of general disease. 
 
 As to the origin of this type of loose body authori- 
 ties differ. While most surgeons • regard them as 
 overgrowths of the synovial fringes within the joints, 
 some maintain that they invariably arise as a result 
 of injury by detachment of a portion or portions of 
 an articular surface. 
 
 Konig regards them as due to a detachment of 
 portions of the articular surfaces by a morbid 
 process to which he has given the name of ' osteo- 
 chondritis dissecans '. 
 
 On the other hand there is much to justify the 
 assumption that they may come into existence in 
 the same way as innocent new growths do in other 
 parts of the body, and are therefore really neoplasmic 
 in nature. 
 
 The accompanying radiogram (Fig. 16) was made 
 from an injured knee-joint. It shows the partial 
 separation of a portion of the external condyle of 
 the femur. 
 
 It is probable that in the course of time this 
 fragment would have become wholly detached and 
 given rise to a loose body freely movable in the 
 articulation. 
 
 Fig. 44 is from a photograph taken of a portion 
 of a patella which had become detached some years 
 previous to its removal. It should be noted that 
 this specimen presents for the most part a smooth 
 
SEQUELS OF SPRAINS 69 
 
 and polished surface. Even that portion of it which 
 originally at the time of its first detachment was rough 
 and irregular is seen to have become smoothed over 
 by the growth over it of hyaline cartilage. The car- 
 tilage would seem to have grown over the specimen 
 from its circumferential margin so as to eventually 
 encroach upon and completely cover over its frac- 
 
 FiG. 17. Kepresents structures removed from the same knee-joint. 
 That on the left is a portion of a much flattened internal semilunar cartilage 
 which had become displaced. The middle one is a portion of the thickened 
 synovial membrane, with papillae developing, while the specimen on the 
 right is the much thickened Ugamenta alaria, with a pedunculated carti- 
 laginous body attached. A history of the case is given in the text. From 
 a photograph somewhat enlarged. 
 
 tured surface. The result is that from what was 
 once an irregular and somewhat flattened fragment, 
 we find a smooth and polished, somewhat rounded 
 loose body. 
 
 Fig. 17 represents a photograph taken of struc- 
 tures removed from the knee-joint of a man of 
 middle age. The patient had detached a portion 
 of one of his internal semilunar cartilages early in 
 
70 SEQUEL.^ OF SPRAINS 
 
 life and had suffered afterwards from many attacks 
 of relapsing synovitis. 
 
 On the left of the figure the structure represents 
 a portion of the detached cartilage. It is much 
 wider from side to side than is natural. The flatten- 
 ing-out process has been produced by the cartilage 
 having been from time to time caught between the 
 articular surfaces of the bones during the movements 
 of the joint. In its structure are signs of commenc- 
 ing calcification. 
 
 The middle figure represents a portion of the 
 synovial membrane much thickened and hyper- 
 trophied, showing numerous papillae of different 
 sizes as growing from its visceral surface. 
 
 The figure on the right of this depicts the remains 
 of the ligamenta alaria removed from the inter- 
 condyloid region of the joint, also at the time of 
 operation. It may be noticed that the alar liga- 
 ments have become very fibrous and so drawn out 
 as to represent two firm bands. Attached to one 
 of these ligaments were two oval highly-polished 
 pedunculated bodies, one of which is shown in situ. 
 
 The case is interesting and unique as affording 
 an opportunity for studying the consequences which 
 may follow on the neglect of a knee-joint in which 
 there is present a detached semilunar cartilage. 
 
 The movements of the piece of semilunar cartilage 
 which had become separated and loose within the 
 joint for years gave rise to a very chronic form of 
 synovitis. As a result the synovial membrane 
 became much thickened and roughened. On its 
 visceral surface the papillae increased in size, so 
 that the interior of the whole joint was studded 
 
SEQUELS OF SPRAINS 71 
 
 with numerous minute papillae in various stages of 
 development. The ligamenta alaria had become 
 attenuated and converted into thin fibrous bands ; 
 and from the inter-condyloid attachments of these 
 two very well-formed pedunculated bodies were to 
 be seen. Their pedicles had not yet become suffi- 
 ciently long to allow of their being nipped by the 
 bones in the normal movements of the joint. One 
 of these oval bodies was cut and examined micro- 
 scopically. It presented histologically a well-defined 
 mass of fibrous tissue in the centre of which were 
 several rapidly-dividing hyaline cartilage cells. Thus, 
 in these pictures taken of specimens from the same 
 joint we are able to demonstrate the formation of 
 the two chief types of loose bodies in joints — the 
 one a portion of a semilunar cartilage that had 
 become detached and free through violence ; the 
 other type, the result of true growth and develop- 
 ment, taking place in the tissues of the joint as 
 a result of the undue stimulation of a constant and 
 prolonged irritation. 
 
 It is furthermore quite conceivable that had this 
 individual at some time contracted tuberculosis that 
 the deposition of the homogeneous or laminated 
 fibrinous bodies ('rice bodies') would have been 
 superadded so as to complete the list of the three com- 
 moner varieties of loose bodies with which we are 
 familiar. 
 
 The detached cartilage, it should also be noted, 
 shows distinct signs of calcareous deposition, a 
 possible forerunner of other osteo-arthritic changes 
 presumably about to begin. The writer considers 
 that this case is an important one when considered 
 
72 SEQUEL.^ OF SPRAINS 
 
 from an etiological standpoint. It embodies in itself 
 and illustrates practically the views held by various 
 writers on the subject. 
 
 While, however, the etiology and pathology of 
 loose bodies afford ample opportunity for specula- 
 tion and difficulty, the clinical features and symp- 
 toms, as well as the treatment, are straightforward 
 and simple. 
 
 The symptoms of a loose body caught or nipped 
 between the bones of a joint are very character- 
 istic and will be considered more in detail when 
 dealing later with the subject of displaced semilunar 
 cartilages (p. 135). They are essentially those of 
 sprain and arise from the same cause, viz. over- 
 stretching of ligaments. Pain, swelling and tem- 
 porary loss of function accompany in varying 
 degrees every such accident. 
 
 When a body becomes completely and freely 
 movable as a result of detachment, the patient is 
 usually soon made aware of its peregrinations, and 
 the structure may be observed to move from place 
 to place. When, however, it is moored to its place 
 by means of a pedicle or other attachment it remains 
 in the same locality, while the pain and tenderness 
 experienced on pressure or during manipulations 
 become more localized. 
 
 The resulting synovitis is apt to assume a very 
 chronic and recurrent type. 
 
 Treatment consists in the removal of the loose 
 body by opening the joint. This should be done 
 only under the very strictest aseptic principles. 
 Formerly every device short of opening directly into 
 the joint was practised, so dangerous was the opera- 
 
SEQUEL.E OF SPRAINS 73 
 
 tion and so great the risks of disaster. The surgeon 
 of to-day should no longer have qualms providing 
 his technique is modern and he has full confidence 
 in his assistants. Before opening such a joint, one 
 subjected to an obstinate and chronic synovitis, it 
 is advisable that the patient should be kept in bed 
 for a few days to diminish the amount of effusion 
 and allow ample time for the limb to be properly 
 ^ prepared. 
 
CHAPTER IV 
 
 INDIVIDUAL ARTICULAR SPRAINS 
 Upper Extremity 
 
 The Sterno-clavicular joint, by reason of its 
 great natural mobility, is seldom sprained or dis- 
 located ; occasionally, however, the surgeon meets 
 with such a case. When it does occur, it is generally 
 the result of a pulling form of violence applied so 
 that the extended arm is forcibly dragged outwards 
 and backwards away from its sternal attachment. 
 
 The most common injury is a partial separation 
 of the inter-articular cartilage from the capsular 
 ligament anteriorly. Pain is often considerable, 
 increased with every movement of the limb, and 
 the joint is exquisitely tender to the touch. The 
 effusion into the capsule is probably for the most 
 part blood, as there is often considerable extravasa- 
 tion in the immediate neighbourhood of the joint, 
 spreading far and wide over the upper part of the 
 chest. Diagnosis presents little difficulty ; the bones 
 usually retain their normal relationship. 
 
 Treatment consists in bandaging the limb securely 
 to the side of the chest, with the forearm supported 
 in a sling for three or four days. After this time, 
 massage and movements, active and passive, should 
 be commenced and continued up to the time of 
 complete recovery. Three weeks is the average 
 duration of treatment. 
 
INDIVIDUAL ARTICULAR SPRAINS 75 
 
 The Acromio-clavicular joint, unlike the sterno- 
 clavicular, is more restricted in its range of move- 
 ments, and for this reason is more frequently sprained. 
 The ligaments being strong, are seldom torn across, 
 but are frequently overstretched, so that the injury 
 partakes more of the nature of a strain than a sprain. 
 It may result either from a direct blow or from 
 a heavy fall upon the shoulder. The point of greatest 
 tenderness corresponds with the line of the joint 
 over the ridge of the meniscus. Pain is seldom 
 severe unless undue pressure is brought to bear upon 
 the joint itself ; as a rule there is but little swelling. 
 The diagnosis from fracture of the outer end of the 
 clavicle or of the acromion is often one of extreme 
 difficulty and may sometimes be quite impossible 
 without the assistance of radiography. The history 
 of a fall upon the shoulder is rather in favour of 
 a sprain, while a direct blow is usually followed by 
 a fracture. An exact diagnosis is of much impor- 
 tance, both in the relation to prognosis and treat- 
 ment. These sprains, when neglected, are peculiarly 
 liable to result in a painful joint, and complete cure, 
 even when the injury is treated on rational lines, is 
 often delayed for some unexplained reason. It has 
 frequently been noticed by the writer that a sprain 
 at the acromio-clavicular joint will often take twice 
 as long to get well as will a fracture of the clavicle. 
 This is particularly noticeable in dealing with young 
 athletes, persons who are usually in the best possible 
 health ; in them, complete recovery takes place more 
 quickly from almost any other sprain in the body 
 than it does from the one in question. It may 
 be that in many cases in the past, on which his 
 
76 INDIVIDUAL ARTICULAR SPRAINS 
 
 experience is mainly based, they were really cases 
 of unrecognized sprain-fracture, made worse by early 
 movements and massage. A more extensive use of 
 radiography in the future may alter this view. It is 
 his custom, in all cases of accident insurance, when 
 compensation is sought, to give a guarded prognosis 
 as to the date of recovery. Treatment is best carried 
 out by bandaging the arm to the side with the fore- 
 arm in a sling, leaving the injured part fully exposed 
 to view. Rubbing should not be commenced till 
 ' the bruising is coming out ', usually after the third 
 day. Movements of the joint had better be post- 
 poned for a week, for immediate movements do more 
 harm than good. If all the pain has disappeared in 
 three weeks the case may be considered to have 
 done well. There is seldom any after-stiffness or 
 muscle-wasting. If the pain should return, especially 
 if it be nocturnal, rheumatic or gouty remedies are 
 indicated ; blistering may be tried in obstinate cases. 
 Sprains of the shoulder- joint. This joint, depend- 
 ing as it does for its stability mainly upon the 
 strength of the surrounding muscles and tendons, 
 and to a less degree upon that of its ligaments, is 
 much more predisposed to dislocation than sprain. 
 Sprains of the shoulder- joint are rare, and result 
 more from the laceration of the tissues arranged 
 around the joint than from tearing of the ligaments 
 themselves. The capsular ligament is so thin, and 
 possesses so little inherent strength, that it is easily 
 torn. This is seldom possible, however, unless the 
 surrounding muscles are caught unawares or are 
 lacerated before the strain is brought to bear upon 
 it. The whole region becomes swollen and tender 
 
INDIVIDUAL ARTICULAR SPRAINS 77 
 
 to the touch, the point of the greatest intensity 
 corresponding with the upper attachment of the 
 long head of the biceps, immediately below the 
 acromion process. The tenderness may be acute 
 along the whole line of the biceps tendon. Any 
 manipulation whereby the head of the humerus is 
 made to move in the glenoid cavity will cause pain, 
 as will any stretching force applied either to the 
 tendons or ligaments. The swelling is occasionally 
 considerable ; not only is the capacious capsule 
 itself full of effusion, but extensive bleeding takes 
 place into the tissues around. The haemorrhage is 
 mainly from the vessels of supply to the muscles and 
 tendons that have been torn across, and the blood 
 may be diffused into the loose tissue of the axilla, or 
 into the inter-muscular spaces, or it may become 
 collected into definite hsematomata between the 
 fibres of the deltoid muscle, or in the large bursa 
 (sub-deltoid) situated between this muscle and the 
 capsule of the joint. The swelling often renders the 
 differential diagnosis a matter of considerable diffi- 
 culty, so that an examination with an anaesthetic 
 or radiography is often not only advisable but 
 indispensable. This particular injury, especially 
 when there has been much bruising, is very liable to 
 be followed by prolonged pain and stiffness in the 
 upper arm, with considerable crippling. The muscles 
 around, and which move the joint, notably the 
 deltoid, supra- and infra-spinatus, not infrequently 
 undergo rapid atrophy. Neuralgic pain, usually 
 attributed to neuritis and referred to the neighbour- 
 hood of the deltoid insertion, is often complained of. 
 It probably results from the circumflex nerve or its 
 
78 INDIVIDUAL ARTICULAR SPRAINS 
 
 branches being caught and pressed upon in the 
 matting together of the muscles by the extravasated 
 material outside the capsule of the joint. As soon 
 as an exact diagnosis has been arrived at, and all 
 complications excluded, treatment should be begun. 
 When the surgeon is called to see a case soon after 
 the injury, his first aim should be to check or limit 
 the amount of extravasation, for the quantity of 
 blood poured out has an important influence in 
 the later management. This may be best effected 
 by the early application of elastic compression. 
 The axilla should be well padded and the whole 
 region of the joint smoothly covered with cotton 
 wadding, over which a firm spica bandage is applied. 
 When, however, the case is not seen until later, at 
 the time when the swelling has reached its maximum 
 and the patient is unable either to abduct or to 
 adduct his arm, or indeed to move it in any way 
 without causing intense suffering, warm applications 
 are very comforting and may relieve the tension to 
 a certain extent. Flannels wrung out of warm lead 
 lotion or a decoction of poppyheads may be wrapped 
 around for an hour or two. These warm applications 
 find their particular use with a greater certainty in 
 sprains of the shoulder than perhaps in any other 
 joint. In a short time, say in two or three hours, 
 elastic pressure may be substituted. By this time 
 the patient will have lost some of that intense aching 
 and the sense of stretching which so often accom- 
 pany rapid swelling, and will more readily submit 
 to the application of a bandage. Whenever it is 
 feasible, during the early stages of treatment, the 
 elastic pressure should be removed and re-applied 
 
INDIVIDUAL ARTICULAR SPRAINS 79 
 
 twice at least in the day. When there is a large 
 collection of blood in the axilla, or when the sub- 
 deltoid bursa is over-distended and painful, so that 
 a bandage cannot be worn with any comfort, it is 
 often advisable to aspirate and draw off the fluid 
 parts of the blood as a preliminary to the application 
 of pressure. In a few cases of very severe contusion 
 of the shoulder, in which large hsematoma were pre- 
 sent, it has been found of great advantage to make 
 an incision through the deltoid, and to turn out all 
 the clots in its substance or in the bursa beneath it. 
 Sprains of this joint are always, when severe, accom- 
 panied by much bruising, so that the treatment of 
 sprain is largely the treatment of contusion. Massage 
 should never be commenced until the swelling has 
 distinctly begun to subside, though gentle move- 
 ments of a voluntary type may be allowed from the 
 first. In making passive movements, care should 
 be taken not to rub the head of the humerus against 
 the glenoid cavity. The shoulder-girdle should be 
 fixed by an assistant while the surgeon goes gently 
 through the various movements, commencing with 
 flexion and extension, followed by rotation, leaving 
 abduction till the last. As most sprains occur when 
 the arm is in the abducted and extended position, 
 it stands to reason that the lower part of the capsule 
 suffers the greatest damage. Abduction is generally 
 resisted for a considerable time, and for two reasons. 
 When the arm is raised, the sub-deltoid bursa is 
 pressed upon and squeezed, and the biceps tendon 
 is made to slip in its groove ; both of these move- 
 ments are painful. The pain of abduction may some- 
 times be partially overcome by simply employing 
 
80 INDIVIDUAL ARTICULAR SPRAINS 
 
 stroking massage for a few minutes immediately 
 before the passive movements are tried. Passive 
 movements find their greatest value in the treatment 
 of sprained and contused shoulders. Voluntary 
 movements, however slight, must be made from the 
 earliest stages, and continued until complete restora- 
 tion to function is re-established. Unless this detail 
 is carefully attended to, rapid wasting, not only of 
 the deltoid but of all the muscles on the proximal 
 side of the joint, is likely to supervene. Even when 
 the arm is bandaged to the side, movements in the 
 forearm and hand should be made, for this allows 
 nervous impulses to pass to all the muscles of the 
 arm. The bad results ensuing from neglected sprains 
 and contusions are due to an improper appreciation 
 by surgeons of the fact that it is the matting together 
 of the tissues surrounding the joint, and not the 
 tearing of the ligaments themselves, that is responsible 
 for the stiffness and pain afterwards. Every effort 
 should therefore be made throughout the whole charge 
 of the case to prevent or break down these adhesions 
 by movements and massage. A shoulder that has 
 become stiff and painful through neglect and 
 indifferent treatment should in the first place^ be 
 thoroughly moved under an anaesthetic, so as to have 
 all the adhesions completely broken down, and from 
 that time onwards treated as a recent sprain. 
 
 In very extreme cases, even after the stiffness and 
 pain have gone, muscular atrophy may never be 
 completely recovered from, and a weakened joint 
 remains. The only treatment which seems of real 
 value in cases exhibiting considerable muscle-wasting 
 is a continued and systematic course of muscular 
 
INDIVIDUAL ARTICULAR SPRAINS 81 
 
 exercises. It is usually recommended that exercises, 
 arranged so that the muscles act against resistance 
 (as are carried out by means of weights and pulleys 
 or with the aid of elastic cords or bands), should be 
 practised at a gymnasium under ah instructor. 
 Without underestimating the value of any form or 
 forms of active voluntary movements, whenever they 
 are performed regularly and systematically, the 
 writer thinks that much can be done by the patient 
 himself at home. In the earlier stages, at any rate, 
 a gymnasium is quite unnecessary, nor is any definite 
 apparatus required. All that is wanted is that the 
 individual should be clearly instructed as to what 
 movements are required and what it is that these 
 are expected to do for him. He will be able to pre- 
 vent or even overcome atrophy by the simple ex- 
 pedient of extending both arms, clenching firmly his 
 fists (whereby all the muscles of the arm and forearm 
 are made tense), then very slowly and gradually 
 flexing the wrists, then the elbows, at the same time 
 that he lifts both arms as high as possible above his 
 head. This should be done three or four times in 
 a day, actual fatigue being always avoided. The 
 system of making the muscles contract firmly with- 
 out giving them too much work, as is often done 
 when dumbbells are used, is all that is required for 
 developing healthy muscles during athletic training. 
 The same principle will be found equally successful 
 when applied as a means of regenerating muscles 
 that have atrophied ; it has the additional advantage 
 of not requiring any special apparatus. 
 
 The elbow- joint is very frequently sprained as 
 the result of a fall on to the outstretched hand, or 
 
 ^VHITELOCKE a 
 
82 INDIVIDUAL ARTICULAR SPRAINS 
 
 from a twist of the forearm. The damage is generally 
 greatest to the external lateral and orbicular liga- 
 ments, but any of the ligaments may be injured. 
 Effusion takes place into the synovial cavity, and 
 the joint becomes rounded off and swollen, while the 
 natural hollows around it are filled up and disappear. 
 
 The diagnosis must be made from fracture and 
 dislocation, and in children, from partial separation 
 of an epiphysis. In sprain, the bony points about 
 the joint retain their normal relationship ; this fact 
 is sufficient to establish the diagnosis ; should there, 
 however, be any doubt, radioscopy will be useful. 
 Of partial separation of an epiphysis in a child it is 
 often difficult to make certain, even with the aid of 
 the X-rays. A very tender spot in the line of an 
 epiphysis will often put the observer on his guard. 
 Treatment resolves itself into elastic compression 
 until all effusion has disappeared, followed by early 
 movements and massage. Complete recovery may 
 be expected in from fifteen to seventeen days. 
 
 * Dislocation by Elongation,' or * Pulled Elbow '. 
 A subluxation of the head of the radius, though 
 technically a dislocation, may be considered clini- 
 cally as a sprain. It is met with in children under 
 six, and results from the child being lifted or 
 dragged by the hand, and is usually on the left 
 side. It is of not infrequent occurrence. The pulling 
 and twisting of the forearm disengages the head 
 of the radius from the orbicular ligament. The 
 peculiar attitude struck by the forearm is due to the 
 edge of the ligament passing between the bones, 
 and in this way preventing rotation. The child 
 complains of pain, and is unable to use its arm ; 
 
INDIVIDUAL ARTICULAR SPRAINS 83 
 
 the forearm remains halfway between pronation and 
 supination. When an attempt at supination is made, 
 severe pain is complained of at the elbow. There is 
 remarkably little deformity, although the head of 
 the radius may be seen projecting in front of the 
 joint. The wrist is also painful, for it is strained 
 by the same lifting process, and there may be even 
 effusion into this joint, with swelling. The child is 
 usually brought complaining of the pain at its wrist 
 rather than at the elbow, and it is only after an 
 examination has been made that the double injury 
 is discovered. As this is, in the main, a true sprain 
 of the wrist, it has been considered right to place 
 this injury amongst the sprains. Reduction fre- 
 quently takes place spontaneously, and the arm 
 resumes its wonted mobility. Whenever in a child 
 under six both the elbow- and wrist- joints are found 
 full of effusion, this particular injury may be sus- 
 pected. 
 
 Treatment. A general anaesthetic is necessary, 
 for the manipulations are painful. The elbow is 
 flexed, and while traction is made on the forearm, 
 pronation and supination are alternately practised. 
 When reduction has been effected, both the joints 
 should be strapped with plaster, and the forearm 
 placed and kept in a sling. Massage over the strap- 
 ping may be commenced from the very first. In the 
 course of about ten days the movements in both 
 joints should be painless and free. 
 
 * Sprained Elbow ' is a term used for a painful 
 
 condition of the muscles arising from both condyles 
 
 of the humerus and produced by excessive or faulty 
 
 exercise of these muscles, chiefly of the supinator 
 
 G 2 
 
84 INDIVIDUAL ARTICULAR SPRAINS 
 
 longus and the extensores carpi radiales longiores et 
 breviores. Many forms of exercise, such as lawn-« 
 tennis, fly-fishing, golf, and handling a coaching- 
 whip, may produce it. The pain radiates from the 
 condyles downwards into the forearm. As it is in 
 reality and more properly a muscular sprain it will 
 be referred to when treating of muscular sprains. 
 
 Fig. 18. Fracture through lower end of radius without displacement, 
 resulting from bang of swinging gate against the outstretched hand of 
 a young lady while riding. Symptoms only of sprain; real condition 
 detected by radiography. (Mr. Edwin Dcning's case.) 
 
 The inter-muscular septa and fasciae of the forearm 
 are occasionally overstretched or torn, as evinced by 
 the exceptional presence of a muscle hernia, and the 
 marked discoloration of the skin which follows on 
 later. 
 
 Sprain of the Wrist. Simple sprain is a very 
 common injury and results from a fall upon the hand 
 
INDIVIDUAL ARTICULAR SPRAINS 85 
 
 and various twisting forms of violence incidental to 
 athletic exercises. Pain and swelling, with loss of 
 function, are the chief symptoms. The swelling is 
 
 EiG. 19. Fracture of the tip of stjdoid process of the ulna. From 
 symptoms was regarded as simple sprain. Fracture detected late in the 
 treatment by the X-rays. 
 
 often considerable, and renders the diagnosis diffi- 
 cult. This has to be made from CoUes's fracture, 
 fracture of the styloid processes of the radius or 
 ulna, separation of the radiocarpal epiphysis, from 
 
86 INDIVIDUAL ARTICULAR SPRAINS 
 
 dislocation of the radiocarpal articulation, and from 
 fracture of one of the carpal bones. 
 
 It is of the greatest importance to ascertain 
 whether there is a fracture of one of the carpal bones. 
 
 Fig. 20. Sprain-dislocation at wrist, with partial displacement out- 
 wards of the hand with the lower epiphysis of the radius, and showing 
 some tearing of the periosteum of the diaphysis. Symptoms those of 
 sprain. 
 
 The normal relationship of the styloid processes to 
 the other bony points is of importance, for they 
 remain normal in simple sprains. 
 
 The swelling is most marked anteriorly and pos- 
 teriorly along the line of the joint, and, besides this. 
 
INDIVIDUAL ARTICULAR SPRAINS 87 
 
 there is usually some effusion running up the sheath 
 of the tendons into the forearm and down into the 
 hand. 
 
 Treatment consists of elastic pressure, strapping. 
 
 Fig. 21. Complicated sprain of wiist. GreensticJi fracture through 
 lower end of the radius without displacement ; also detachment of the 
 tip of the epiphysis at the lower end of uhia. Exact condition determined 
 only by the help of radiography. Originally thought to be simple sprain. 
 
 early movements, with or without massage. It is 
 impossible to determine the presence or absence of 
 a fracture through one of the carpal bones without 
 
88 INDIVIDUAL ARTICULAR SPRAINS 
 
 the X-rays. The writer has, during the last year, 
 met with three cases of fracture of the scaphoid 
 bone, all of which had at first been regarded as 
 ordinary simple sprains. Two of these had occurred 
 
 Fig. 22. Fracture of scaphoid. Fractuie -sprain of wrist; symptoms 
 only of simple sprain ; result of misplaced blow with the fist while boxing. 
 The bone is split into three pieces. 
 
 some weeks before the writer saw them ; the third 
 was seen directly after the accident. A correct 
 diagnosis was made, in all three cases, by means of 
 radiography, without which it could not have been 
 established. 
 
 As the condition is such a rare one, and the treat- 
 
INDIVIDUAL ARTICULAR SPRAINS 89 
 
 ment so dependent upon an accurate diagnosis, it 
 has been thought wise to record the cases somewhat 
 fully. 
 
 The accompanying photographs, which were taken 
 for the writer by Dr. Richard Sankey, Hon. Radio- 
 grapher to the Radcliffe Infirmary at Oxford, show 
 
 Fig. 23. Fracture of scaphoid bone of right wrist, result of a Rugby 
 football accident. Patient had been treated by movements and massage 
 on the assumption that it was a case of simple sprain. For details vide 
 text. 
 
 very distinctly in each case the presence of a fracture 
 through the scaphoid bone. The patients were all 
 undergraduates, and distinguished athletes. The 
 injuries were produced by different forms of athletic 
 exercise and in different ways. 
 
 In the first case the patient was a heavy-weight 
 boxer, and while delivering a blow struck the end 
 
90 INDIVIDUAL ARTICULAR SPRAINS 
 
 of his clenched fist so as to drive it somewhat to the 
 radial side and almost directly backwards on to the 
 wrist, the muscles of the forearm being at the time 
 firmly contracted. 
 
 The second case was that of a Rugby football 
 player who fell while running with the ball. 
 
 Fig. 24. Fracture of scaphoid bone of carpus, from Association football 
 goalkeeper's accident. Symptoms same as those of sprain; diagnosis 
 only possible by X-rays. Treated by rest for fourteen days and later 
 by movements. 
 
 The third was the University Association football 
 goalkeeper, who had his hand forcibly wrenched 
 backwards in endeavouring to keep the ball out of 
 goal. The clinical symptoms were remarkably 
 similar in all the cases, so that a description of 
 
INDIVIDUAL ARTICULAR SPRAINS 91 
 
 one will serve for all. The Rugby football player 
 (Mr. W. Elliot Stanford, of New College) was good 
 enough to write out the details of the history and 
 symptoms of his accident. It seems a more or less 
 accurate account of what occurred before and after 
 he came under personal observation, and is here 
 given in his own words. 
 
 ' I was playing Rugby football in the Parks at Oxford, 
 on October 15, 1907, and while running along at top speed 
 I was tackled hard and low, and fell violently towards my 
 right side. My idea is, that in falling, I got my right arm 
 into such a position that my hand was wrenched back by 
 the whole weight of my falling body ; but of this I cannot 
 be quite certain. It might very well have been that the 
 wrist was doubled up underneath me as I fell, and not really 
 forced backwards ; but the former was my impression at 
 the time. The effect was very painful, and the hand and 
 forearm were practically paralysed for the time being. 
 Immediately after the game I returned to college and had 
 a hot bath, the effect of which probably was to counteract 
 the tendency to swell. The wrist had swelled, but not to 
 any great extent, and become stiff, and of course I could 
 not attempt to use it at all. Immediately after the bath 
 I had the wrist bandaged with a cooling liniment, and this 
 treatment I continued for the next few days. The swelling 
 reached its maximum the day after the accident, and then 
 gradually decreased, until the only sign of swelHng was a 
 little thickness in the part of the joint immediately above 
 the baU of the thumb, which remained for some time after. 
 Not knowing that there was any fracture as well as the 
 sprain, I did not as a rule have the wrist bandaged ; I 
 attempted to loosen it by massage, and succeeded to a 
 certain extent. I could not use the hand except merely 
 to hold with the fingers when there was no actual strain on 
 the wrist. I could move my hand backwards and forwards 
 to a small extent and the scope of the movement gradually 
 
92 INDIVIDUAL ARTICULAR SPRAINS 
 
 increased up to a certain point. During the first fortnight 
 I twice jarred the wrist rather badly. On each occasion it 
 was a sudden strain backwards, and after each of these jars 
 the wrist was worse for a time. Any sudden movement of 
 the wrist, however sHght, hurt it. After the first fortnight 
 I could flex the wrist forward, that is towards the palm, 
 until it was bent almost as far as it could be normally ; but 
 the process was rather painful. I could bend the hand 
 backwards to a very limited extent, and any effort to press 
 it further backwards was painful if the fingers were bent, 
 but if the fingers were stretched out, I could force the hand 
 back at will, by a muscular contraction of the forearm, and 
 although it could not be bent any further than when the 
 fingers were flexed, yet, strange to say, it caused no pain, 
 but on the application of external pressure by pressing it 
 back with the other hand it became painful. Since the 
 X-rays examination showed that there had been a fracture, 
 I have been wearing the strapping you recommended, 
 around the wrist, and using it as little as possible. The 
 joint is now a little stronger, but still gives pain on making 
 the movements described above, and I can still feel slight 
 pain on pressing the fingers of the left hand on the thumb 
 side of the right wrist, particularly underneath the part of 
 the joint which is directly above the ball of the thumb ; the 
 joint frequently grates and cracks when I bend it.' 
 
 These details were written late in November, or 
 six weeks after the accident. On July the 29th of 
 last year, he wrote the following additional account : 
 
 . ' I have been exercising my damaged wrist lately, and at 
 present it seems to be troubling me less than it did a month 
 or two ago. There is now very little stiffness or pain in 
 palmar and ulnar flexion, if the movements are steady, but 
 any sudden movement, particularly if unexpected and 
 therefore unresisted, still produces a sharp pain in the 
 region of the fractured bone. From a position in which 
 the fingers are in the same line with the forearm it is impos- 
 
INDIVIDUAL ARTICULAR SPRAINS 93 
 
 sible to flex the joint radially, either by passive or active 
 movement, and any effort to do so is attended with pain 
 of a sharp and burning nature, when the movement is 
 sudden and unexpected, if for instance I catch my thumb 
 in putting my hand into my pocket. I cannot bend my 
 hand back any further than I could months ago ; it resists 
 both active and passive movements beyond a certain angle, 
 about 5° from the normal limit of dorsal flexion ; but while 
 attempts to force it further are painful, active force produces 
 very Uttle pain. This restriction I find a great handicap, 
 as it prevents me from pressing away with my palm unless 
 I keep my elbow bent. The palmar surface of the wrist is 
 still slightly thickened below the root of the thumb, and if I 
 let my hand hang and press against a certain small spot on 
 the inside of the small hard lump, a sUght click is produced 
 which hurts slightly the first time, but repetition does not 
 produce further pain. I ought to have said, in referring to 
 the palmar flexion of the wrist, that the freedom of flexion is 
 less on the thumb side than on the other, with the conse- 
 quence that there seems to be a certain amount of ulnar 
 flexion involved. The ^vrist cracks and grates to a certain 
 extent when I exercise it.' 
 
 The history and progress of this case is, as was 
 stated before, very similar to that of the boxer's. In 
 each of these two cases the injury was, in the first 
 instance, regarded as a simple sprain and treated 
 by early and continued movement, and resulted in 
 the same unsatisfactory manner. In the goalkeeper's 
 case the symptoms at first were similar, but as an 
 immediate diagnosis was made with the help of 
 radiography, instead of early passive movements 
 and massage being used, the wrist was strapped and 
 the arm worn in a sling for a fortnight. No massage 
 was allowed until after this time, although each day 
 gentle voluntary movements of the fingers were 
 
94 INDIVIDUAL ARTICULAR SPRAINS 
 
 practised while the present writer firmly grasped 
 and supported the wrist. The result was that the 
 case was completely cured, so that the goalkeeper 
 was able to play football in six weeks from the time 
 of his injury. He made an excellent recovery, bony 
 union having probably taken place. In the former 
 two cases the fragments remained detached, so that 
 each carpus now virtually contains nine bones 
 instead of eight. Until by long-continued move- 
 ments the fragments of the scaphoid should become 
 sufficiently polished, or so covered by hyaline car- 
 tilage, that they move smoothly upon one another, 
 it is likely that stiffness, pain, and limited movements 
 will continue. 
 
 This group of cases admirably exemplifies the 
 statement made elsewhere, that sprains with frac- 
 ture must be treated in a way quite different from 
 that used for simple sprains. Massage and early 
 passive movements are not only useless, but harmful. 
 Such a sprain should be allowed complete rest for 
 at least ten days ; any subsequent stiffness and 
 tendency to atrophy being prevented by allowing 
 gentle and judicious voluntary movements in the 
 fingers, and it is only in the later stages that massage 
 is really of service. 
 
 The patients are all well-known athletes at the 
 University ; the boxer was a heavy-weight cham- 
 pion, and the goalkeeper represented his University 
 last year against Cambridge six weeks after the 
 accident. 
 
 The three accompanying photographs show plainly 
 the precise degree of fracture in each case. 
 
 Sprains of the thumb are very frequently met 
 
INDIVIDUAL ARTICULAR SPRAINS 95 
 
 with in athletes. They result from any form of 
 violence sufficient to overstretch or tear the liga- 
 ments either of the carpo-metacarpal or the meta- 
 carpo-phalangeal joints. The symptoms are pain. 
 
 25 26 
 
 Fig. 25. Fracture at base of metacarpal bone of the thumb, resulting 
 
 from a fall on to the abducted and outstretched thumb. No crepitation 
 
 could be felt, and the symptoms were only those of sprain. 
 
 Fig. 26. Fracture at base of metacarpal of the thumb. Treated 
 
 formerly as simple strain. Radiogram shows detachment of fragment. 
 
 Bennett's fracture so-called, dorsal view. 
 
 TbiCa^^ 
 
96 INDIVIDUAL ARTICULAR SPRAINS 
 
 swelling and stiffness. The pain is increased by any 
 form of movement. It must be distinguished from 
 the fracture occurring at the base of the metacarpal 
 bone first described by Bennett of Dublin, and which 
 has since taken his name, also from fractures of the 
 body of the metacarpal bone itself. The accom- 
 panying photograph is from a case in which there 
 
 Fig. 27. Linear fracture of metacarpal bone of the thumb. No 
 displacement. Carpo-metacarpal and metacarpo-phalangeal joints both 
 full of effusion. Had been treated as sprain imtil X-ray revealed 
 presence of fracture. Result of accident at cricket. 
 
 was a linear fracture through the metacarpal bone 
 and which was at first regarded as one of simple 
 sprain. In this case there was effusion, both into 
 the carpo-metacarpal and the metacarpo-phalangeal 
 joints. It occurred in the person of the University 
 wicket-keeper, and was the result of a direct blow 
 from a cricket ball. No symptoms of fracture could 
 
INDIVIDUAL ARTICULAR SPRAINS 97 
 
 be detected, and it was only after the usual methods 
 of treatment for sprain had failed to remove the 
 symptoms that a fracture was suspected and an X-ray 
 photograph made. By referring to the picture the 
 spUt in the bone may be seen quite distinctly, though 
 there is no evident displacement of the fragments. 
 
 The treatment of simple sprain of the thumb is by 
 means of plaster strapping, with movements and 
 massage from the very earliest time. Stiffness is 
 likely to remain unless the movements are main- 
 tained for some time after all pain has disappeared. 
 Sprain-fractures, and sprains with fracture on the 
 other hand, must be treated as fractures, and not by 
 indiscriminate movement ; it is essential that they 
 should be rested at first. 
 
 * Drop-top,' or * mallet finger', is a sprain of 
 the attachments of the long extensors of the thumb 
 and fingers to the dorsum of the terminal phalanges. 
 It is met with in cricketers, chiefly wicket-keepers, 
 and results from a cricket ball striking the tips of the 
 fingers when they are extended as in the act of 
 catching. The digits are forcibly flexed and the 
 attachments of the extensor tendons are either con- 
 siderably overstretched or completely separated 
 from their phalangeal attachments. The terminal 
 phalanx droops forward, and although it may be 
 completely restored by manipulation, the patient is 
 unable to extend it at wiU. The resulting dis- 
 figurement is often unsightly. The writer knows an 
 old professional wicket-keeper who has one thumb 
 and six fingers crippled in this way. The accom- 
 panying photograph is from the hand of a school- 
 boy in whose case there was an oblique fracture 
 
 WHITELOCKE jj 
 
98 INDIVIDUAL ARTICULAR SPRAINS 
 
 through the phalanx, a fracture-sprain, and not a 
 true sprain as it was first thought to be. The 
 deformity at first sight closely resembles drop-top. 
 
 28 
 
 29 
 
 Fig. 28. Radiogram of fractured phalanx of index finger, the result 
 of a fall. Had been treated as a sprain by movements and massage. 
 Without X-rays the fracture could not be detected, as the displacement 
 was very slight and the swelling very marked. 
 
 Fig. 29. Profile view of a greenstick fracture of the first phalanx of 
 finger. Symptoms those of simple sprain. 
 
 and but for the X-rays might have been mistaken 
 for that condition. 
 
 The treatment is to fix the finger to a dorsal splint 
 
INDIVIDUAL ARTICULAR SPRAINS 99 
 
 extending beyond its tip, and to strap the phalanx 
 to it with plaster. Movement and massage should 
 not be used for at least fourteen days. The result is 
 often disappointing, and in the case of the thumb 
 
 Fig. 30. Fracture (greenstick) of metacarpal bone of middle finger. 
 No displacement, but showing callus. Had been treated as a sprain of 
 hand, resulting from a fall. 
 
 causes considerable inconvenience. On a few occa- 
 sions the writer has operated and stitched the end 
 of the detached tendon to the periosteum, having 
 taken the tendon as far forward as possible, then 
 
 H 2 
 
100 INDIVIDUAL ARTICULAR SPRAINS 
 
 fixed the finger in the hyper-extended position by 
 means of a moulded spHnt, which was worn for about 
 three weeks. The result in four of the seven cases 
 was good ; in the remaining three there was marked 
 improvement, though the power of extension was 
 never complete. The method, however, is useful, 
 and may be recommended where the deformity is a 
 source of annoyance to the individual. In two of 
 the cases the patients were anxious to enter the public 
 services, one the Army, the other the Indian Civil 
 Service ; they were both finally admitted. 
 
 Sprains of the Lower Extremity 
 
 Sprains of the hip are comparatively rare and 
 result from any form of violence which causes over- 
 stretching or laceration of the ligaments. There is 
 often considerable effusion into the joint, and the 
 whole articulation is tender on pressure, and painful 
 when moved, however slightly. It assumes the 
 position of slight flexion, with abduction and external 
 rotation, that which, owing to the distension of the 
 capsule, affords the greatest amount of ease. On 
 measurement it will be found that there is no altera- 
 tion in the relation of the bony points to one another, 
 and that there is no shortening. At first, especially 
 when there is much swelling and bruising around the 
 joint and the tenderness is marked, it is exceedingly 
 difficult to exclude fracture. In such cases it is a wise 
 plan to treat it as if it were one of fracture by putting 
 the patient to bed and watching for other symptoms. 
 
 The prognosis of sprains and contusion of the hip 
 in persons of middle age and onwards should be 
 guarded. There are many cases on record in which 
 
INDIVIDUAL ARTICULAR SPRAINS 101 
 
 it would appear that a simple strain was the deter- 
 mining factor for osteo-arthritic changes, which after- 
 wards made the joint absolutely stiff. The gluteal 
 muscles are liable to considerable wasting. 
 
 As to treatment, the individual should be put to 
 bed and kept there for some days ; no splint is neces- 
 sary, and none should be allowed. Friction massage 
 of the thigh and buttock may be commenced early. 
 Elastic pressure is not convenient. Active move- 
 ments of the foot and bending of the knee and ankles 
 should be encouraged all the time, and as the pain 
 diminishes the patient may be allowed to turn him- 
 self in bed and to flex the joint itself. These move- 
 ments are most beneficial when repeated several times 
 in the day. Passive movements and kneading 
 massage are of more service late in the case, beginning 
 usually about the tenth day, or about the time that 
 the patient should first be allowed to get out of bed. 
 The movements and rubbing must be continued regu- 
 larty and carried out systematically for at least a fort- 
 night after the patient is able to walk. The muscles 
 rapidly waste and become weak and therefore require 
 strict attention during the whole period of treatment, 
 and on to the time of complete recovery. Joints 
 that are treated by fixation are the ones most prone 
 to osteo-arthritis and permanent stiffness. 
 
 Contusions of the hip or its neighbourhood should 
 be treated in the same way as sprains, i. e. by rest in 
 the early stages, followed later by massage and 
 movements. 
 
 Sprains of the knee are considered in a separate 
 chapter. 
 
 The ankle-joint is, next to the knee, perhaps the 
 
102 INDIVIDUAL ARTICULAR SPRAINS 
 
 most frequently sprained of all the joints. It is 
 peculiarly liable to twists and strains, from persons 
 slipping off a kerb, while strains at football and 
 other games are frequent causes. The strong lateral 
 ligaments suffer most, but the tendons around the 
 
 Fig. 31. To illustrate a severely sprained ankle. The photograph was 
 taken to show the effect of an improperly applied elastic bandage. The 
 indentation seen is the result of tightly bandaging the limb without 
 sufficient wadding. Note the characteristic appearance of bruising around 
 the joint. 
 
 joint come in for a good deal of stretching ; more 
 rarely, the anterior annular ligament is partially 
 severed. 
 
 Owing to the inherent strength of the lateral liga- 
 ments, and the support given to the joint by the two 
 malleoli, it not infrequently happens that small por- 
 
INDIVIDUAL ARTICULAR SPRAINS 103 
 
 tions of either or both of these bony points become 
 detached with the Hgaments. A careful search 
 should in all cases be made to ascertain whether or 
 not any bony defect is present. The prognosis and 
 treatment vary according to the presence or absence 
 of injury to the bones. Fractures in the lower end 
 of the fibula should be excluded. The diagnosis of 
 fracture is often difficult when there is no displace- 
 ment. The accompanying photograph (Fig. 32) shows 
 a linear fracture high up in the lower third of the tibia 
 without any displacement, as a complication of a 
 sprain of the ankle. The patient, a lad of fourteen, 
 was treated for ordinary sprain, as all the usual 
 symptoms were present, and the fracture was not 
 detected until the limb had been subjected to the 
 X-rays. He was able to walk into hospital at the 
 time of admission, two days after the accident. 
 
 Many sprain-fractures occur at this joint. It is 
 of the first importance that all severe sprains in the 
 region of the ankle should be X-rayed. Displaced 
 tendons, though rare, are occasionally found. The 
 symptoms are pain, effusion into the joint, and loss 
 of function : pain and tenderness, increased on pres- 
 sure over the torn ligaments and in all movements. 
 The swelling is often much increased by the efforts 
 made by the patient to walk. There may be con- 
 siderable subcutaneous extravasation of blood, on 
 some occasions extending from the ball of the little 
 toe to half-way up the leg, following the lines of the 
 tendon-sheaths. 
 
 The most suitable treatment for strains when there 
 is little or no effusion is strapping. This should be 
 applied in overlapping strips and laid on smoothly. 
 
104 INDIVIDUAL ARTICULAR SPRAINS 
 
 Beginning at the ball of the toes, the strips of plaster 
 should be crossed in front of the joint so as to cover 
 
 Fig. 32. Linear fracture of tibia in lower third without displacement, 
 from a boy who walked into hospital complaining of having sprained his 
 ankle. The fracture does not extend to the joint. Radiogram taken 
 two days after the accident. 
 
 it completely and give firm support. (For special 
 method of strapping vide Appendix.) In the 
 slighter cases the patient may be allowed to stand 
 
INDIVIDUAL ARTICULAR SPRAINS 105 
 
 as soon as the plaster has been apphed. Movements^ 
 in the toes and sUght flexion and extension at the 
 ankle should be encouraged daily, even if a certain 
 amount of pain is experienced. Whenever the 
 strapping becomes loosened it should be immediately 
 re-applied and continued to be worn until all pain 
 has disappeared and the strength and movements in 
 the joint are fully restored. Massage may or may 
 not be needed. 
 
 When there is effusion into the capsule and extra- 
 vasation into the tissues around the malleoli and into 
 the tendon-sheaths, no plan succeeds so well as 
 elastic pressure. This should be applied as soon as 
 possible, the sooner the better, and removed and 
 re-applied two or three times a day. Massage and 
 passive movements should not be allowed until all 
 the effusion within the capsule has gone ; after this 
 they may be practised with much advantage. Active 
 movements should be commenced from the very 
 first and continued throughout the treatment, but the 
 weight of the body should not be forced upon the 
 ligaments for at least ten days after the accident. 
 The prognosis is good in all simple sprains, providing 
 the patient is not allowed to walk too soon. A 
 neglected sprain renders the joint either painful or 
 weak, or both. If walking is permitted before the 
 fluid has disappeared, or before the ligaments are 
 sufficiently strong to support the weight, a relapse is 
 almost certain to follow. There is nothing more 
 tiresome, both to the patient and surgeon, than a 
 weak and painful ankle. 
 
 When walking is first begun it is well that a 
 bandage should be used as a support during the day 
 
106 INDIVIDUAL ARTICULAR SPRAINS 
 
 and removed at bedtime. Strong elastic bandages 
 are to be condemned. An elastic anklet may be worn 
 on the first two or three occasions on which violent 
 exercise is indulged in, but removed as soon after 
 as possible. When worn continually they produce 
 weakness in the joint. 
 
 Cases that relapse after an interval of days or even 
 weeks, when there is absence of fresh injury, are 
 almost invariably due to rheumatism or gout. An 
 acute attack of gout or rheumatism may supervene 
 on an injury to the ankle. These constitutional com- 
 plications should be met by the remedies appropriate 
 to each. 
 
 * Metatarsal pain ' may be classified with sprains. 
 It is of a chronic or sub-acute nature and is dependent 
 upon a stretching of ligaments and perhaps tendons. 
 As its name denotes, it is a painful condition met with 
 in the sole of the foot at the metatarso-phalangeal 
 joints. It may usually be traced to the wearing of 
 tight and improper boots with narrow soles and high 
 heels. The toes are squeezed together and the whole 
 weight of the body is thrown forwards and down- 
 wards on to their bases. The transverse ligaments 
 which bind the heads of the metatarsals together are 
 unduly stretched dorsally as one or other metatarsal 
 bone becomes displaced beneath its neighbour. This 
 stretching force is brought into play whenever the 
 foot is put forward in the act of walking. Some- 
 times there is a limited swelling over the metatarso- 
 phalangeal joints. The anterior part of the sole is 
 tender to the touch, and is often very painful when 
 the individual first attempts to walk after the re- 
 moval of the shoes. 
 
INDIVIDUAL ARTICULAR SPRAINS 107 
 
 The treatment consists in substituting a broad- 
 soled boot with flat heels for the improper one 
 previously worn, and rubbing the foot night and 
 morning with sonie stimulating embrocation. The 
 pain is sometimes so severe as to make walking 
 impossible. When shampooing does not succeed in 
 relieving the pain, wrenching the foot under an 
 anaesthetic, as a preliminary to rubbing, may succeed. 
 The deep friction of an electric vibrating machine 
 has been of service. It is an affection met with in 
 males as well as females. 
 
 The tarso-metatarsal joint of the great toe is 
 occasionally sprained during the performance of 
 athletic exercises. The symptoms and diagnosis 
 present nothing unusual, and the treatment is on 
 general lines. 
 
 Sprains of the body. Besides the muscular sprains 
 of the body, which will be dealt with in a succeeding 
 chapter, we will here mention the 
 
 Sacro-coccygeal sprain. This is a troublesome 
 affection, and may result from a variety of causes, 
 the most usual being from falls on to the lower part 
 of the spine, whereby the ligaments of the coccyx are 
 overstretched or partially torn. The ligaments of 
 the sacro'iliac joints may be injured from the jarring 
 at these joints produced by heavy falls on to one or 
 other tuberosity of the ischium or on to the end of 
 the spine. Falls in the hunting, polo, or football 
 fields have been known to produce it. The symp- 
 toms are pain, usually increased when an attempt is 
 made to rise from the sitting posture or to resume 
 this position after the erect. Tenderness on pressure 
 is usual, and may on occasions be intense. There 
 
108 INDIVIDUAL ARTICULAR SPRAINS 
 
 may or may not be swelling ; it is usual to find none. 
 The diagnosis from dislocation or fracture of the 
 coccyx is made from the absence or presence of pain 
 in defsecation. In fracture or dislocation of the 
 coccyx there is always pain during this act. A finger 
 passed into the bowel will also readily discover a 
 dislocation or fracture of the coccyx. 
 
 The early treatment consists in reducing any dis- 
 placement of the coccyx should one be present 
 (this is done by levering it into position by means of 
 a finger inserted into the rectum, with the aid of an 
 anaesthetic if necessary), then of putting the patient 
 to bed for a few days. The recumbent position is 
 necessary to procure rest as well as to relieve painful 
 defsecation. Should the pain be severe, aspirin 
 may be used, and when absolutely necessary, even 
 morphia. Warm applications to the perineum and 
 lower dorsum are often appreciated. Later, massage 
 and electrical vibrations will be helpful in clearing up 
 any deep effusions. The prognosis must be guarded, 
 for the condition known as coccygodynia, a painful 
 neuralgic affection, may supervene and occasion 
 much trouble, and especially is this true when the 
 subjects are of the neurotic type. 
 
 Various devices and means have from time to time 
 been adopted to relieve the symptoms of this last- 
 named affection. When the pain is very severe and 
 the bruising extensive, the treatment as for a frac- 
 tured pelvis may with advantage be adopted for the 
 first few days, followed later by that for sprain with 
 contusion. 
 
CHAPTER V 
 
 SPRAINS IN THE REGION OF THE 
 KNEE-JOINT 
 
 Surgical anatomy. For the better understanding 
 of the many and varied lesions met with in this part 
 of the body, which, for convenience, are grouped 
 together cHnically as sprains, a short reference to 
 topographical anatomy may be of service. 
 
 As the articular surfaces of the bones of the knee 
 are simply opposed to one another without any 
 interlocking or fixation, and as the integrity of the 
 joint is dependent almost entirely upon the strength 
 and arrangement of its Ugaments and tendons, it is 
 peculiarly liable to sprain. Almost every ligament 
 and tendon, as weU as the synovial membrane, may 
 be at some time or other overstretched or lacerated. 
 
 The capsular ligament is strengthened and sup- 
 ported in various directions by the tendons which 
 pass over and around it. It envelops the whole 
 articulation and encloses the ends of bone as it were 
 in a tube. It receives additional support by the 
 blending with it of processes from the other hgaments. 
 
 It is lined by a synovial membrane of great laxity 
 and extent, which is folded or pleated in various 
 directions and gives off folds which pass inwards 
 between the bones, completely envelops the inter- 
 articular or crucial ligaments, and for the most part 
 surrounds the upper and lower surfaces of the 
 
110 SPRAINS IN THE REGION OF 
 
 inter-articular fibro-cartilages. It is almost invari- 
 ably injured when the capsule is overstretched or 
 torn. 
 
 The "patellar ligament and tendon of the quadriceps 
 extensor represent together a powerful anterior liga- 
 ment, its lateral expansion blending intimately with 
 the capsule on either side. 
 
 The posterior ligament is also of very great strength, 
 and is made up of bundles of fibres passing in almost 
 every direction and reinforced here and there by 
 strips from the tendons at the back and sides of 
 the joint. 
 
 The internal lateral is a powerful ligament, flat 
 and ribbon-like, passing obliquely downwards and 
 slightly forwards from the inner surface of the 
 internal condyle of the femur to the inner surface of 
 the tibia in direct continuation of the line of attach- 
 ment of the adductor magnus tendon to the tubercle 
 of the internal condyle of the femur. The lower 
 attachment extends well below the inner tuberosity 
 of the tibia. It consists of two parts, a superficial 
 and deep. The superficial is about \^ inches wide 
 and is attached above and below to the femur and 
 tibia respectively. The deep portion is as it were 
 an offshoot of the superficial, and, passing deeply, 
 is attached to the convex border or base of the 
 internal semilunar cartilage at its middle, as well 
 as to the capsular ligament in front and behind this 
 point. 
 
 The long external lateral ligament is a cordlike 
 structure of fair strength passing almost parallel 
 with the. internal ligament, attached above to the 
 external condyle of the femur, and below to the 
 
THE KNEE-JOINT 111 
 
 head of the fibula. It is separated from the external 
 semilunar cartilage by the popliteus tendon which 
 intervenes. This tendon grooves the outer border 
 of the semilunar cartilage deeply and gives it 
 support. 
 
 The crucial ligaments are two. The anterior is also 
 external, while the posterior is internal. These 
 ligaments cross one another and bind the femur to 
 the tibia very firmly. They are placed between the 
 condyles of the femur entirely within the joint, are 
 almost completely enveloped by the synovial mem- 
 brane, are of great strength, and are only torn as 
 the result of extreme violence. 
 
 The inter-articular fibro-cartilages are two, the 
 internal larger and the external smaller. Without 
 going into anything like a full anatomical description 
 of these structures, it is necessary that the reader's 
 attention should be directed to certain facts in 
 relation to them : facts which explain the occurrence 
 and the frequency, or otherwise, of certain injuries 
 to which they are liable. The semilunar cartilages 
 may be regarded as the remnants of two complete 
 inter-articular disks placed between the condyles 
 of the femur and the upper surface of the tibia. 
 Through successive periods of time they have become 
 more and more worn away and atrophied towards 
 the centre of the joint, partly owing to the vertical 
 pressure of the weight of the body and partly to the 
 friction produced by the rotation which normally 
 takes place around the tibial spines in every move- 
 ment of the joint, whether in flexion or extension. 
 
 As the internal condyle of the femur is larger than 
 the external and on a lower level, and as in all 
 
112 SPRAINS IN THE REGION OF 
 
 movements it is held more closely applied to the 
 tibia than is the external condyle, so the internal 
 semilunar cartilage is subjected to a greater amount 
 of grinding strain than its fellow. Is it surprising, 
 then, that we find this cartilage more worn away 
 than its neighbour, more attenuated, narrower from 
 side to side, and proportionately weaker ? The 
 wearing away is more at its anterior end than at the 
 posterior. The external cartilage is more movable 
 and is not subjected to as much grinding between 
 the bones as the internal. On rare occasions it is 
 found as a complete disk, or with but a small central 
 foramen. The anterior half of the internal cartilage 
 is weaker than any other part of either cartilage. 
 
 As regards the attachments of the horns of the 
 cartilages it will be seen that the posterior ones have 
 very firm attachments to the tibia ; especially is 
 this the case with the external cartilage, which is 
 reinforced by two fibrous slips. One of these arises 
 from the posterior crucial ligament and the other 
 passes from it to the outer surface of the internal 
 condyle of the femur posteriorly. This latter slip 
 is often absent. The anterior cornu of the external 
 cartilage is also firmly bound down to the tibia 
 while the anterior extremity of the internal cartilage 
 varies greatly in its arrangement and strength of 
 attachment. In some cases it is represented only 
 by a delicate strip which passes right across in front 
 to be attached to the front of the external cartilage, 
 and finds no direct tibial attachment. At other 
 times it is but loosely connected with the upper and 
 anterior border of the tibia, and blends with the 
 capsular ligament or the periosteum, the most 
 
THE KNEE-JOINT 113 
 
 common site for its attachment being to the front 
 of the internal tibial spine immediately anterior to 
 the attachment of the anterior crucial ligament. 
 
 This anatomical variation in the attachment of 
 the anterior horn of the internal semilunar cartilage 
 is largely responsible for the displacements and 
 detachments so frequently met with in the anterior 
 half of this cartilage. To a more detailed con- 
 sideration of the surgical significance of this point 
 reference will again be made when treating of the 
 internal derangements of the knee. 
 
 The body of each cartilage is bound down to the 
 upper edge of its respective tibial tuberosity by 
 means of the coronary ligaments. These bands are 
 of fair strength and are attached to the peripheral 
 convex bases of the cartilages. The internal lateral 
 ligament gives attachment on its deep surface to the 
 internal cartilage, while the popliteus tendon lying 
 in a groove in the outer border of the external 
 cartilage assists in maintaining its position. 
 
 Sprains of the knee are comparatively common as 
 the result of a twist or a wrench. The ligaments 
 are overstretched or torn across partially or com- 
 pletely. The joint becomes much swollen through 
 effusion into it. This effusion extends to the utmost 
 limits of the synovial cavity so that the hollows on 
 each side of the patella are abolished and the quadri- 
 ceps tendon pushed forwards, and when the joint is 
 fuU the patella is raised from the trochlear surface 
 of the femur and made to ' float ' . 
 
 The 'floating patella' may be felt to strike the 
 femur when pressed upon suddenly. It must be 
 mentioned, however, that this symptom of floating 
 
 WHITELOCKE T 
 
114 SPRAINS IN THE REGION OF 
 
 patella may be deceptive, and must not be too 
 much depended upon in making a diagnosis. Begin- 
 ners are wont to overestimate its value. Two facts 
 are important in relation to it ; firstly, the patella 
 does not float unless there is considerable effusion, 
 suflicient to distend the capsule more or less com- 
 pletely : unless this is borne in mind when the 
 symptom is absent, slight effusions may be over- 
 looked ; and, secondly, a degree of floating is present 
 when the synovial membrane itself is thickened 
 and where there may be only very little fluid in the 
 joint. This condition of things exists in certain 
 cases of early tubercular disease and must not be 
 mistaken for effusion. 
 
 I have known a surgeon declare that there was 
 no fluid, because he was unable to make the patella 
 float and rap against the femur. Manipulation of 
 the patella in a sprain is a painful process, and a very 
 unnecessary one for making a diagnosis. 
 
 If the surgeon, on passing his eyes critically over 
 the natural hollows on each side of the patella in 
 a recently injured knee, finds them abolished, he 
 may be absolutely certain that he has to deal with 
 an effusion into the joint and may never need to 
 touch the swelling to establish his diagnosis. On 
 the inner side of the patella, at a point corresponding 
 with the hollow referred to just now, the only 
 structures which overlay the synovial membrane 
 are the skin and fascia, and a thin expansion from 
 the extensor tendon blending with the capsular 
 ligament. The eye is all that is needed to make 
 the diagnosis, and patients may be spared unneces- 
 sary pain if this simple fact is borne in mind. 
 
THE KNEE-JOINT 115 
 
 The differential diagnosis from fracture and 
 separation of epiphyses is not always simple, but 
 careful attention to the normal relationships of the 
 bones will go far in preventing mistakes. 
 
 The point of greatest tenderness in sprains of the 
 knee is usually at the attachment of the internal 
 
 Fig. 33. Photograph from sprained knee four hours after the accident. 
 Note the obUteration of the natural outlines of the joint when comparing 
 it with the other knee. This is typical of full distension of a knee-joint 
 with blood, or synovia. 
 
 lateral ligament to the inner surface of the femoral 
 condyle, less often over the middle of the base of 
 the internal semilunar cartilage. When the external 
 lateral ligament is most affected, and this is rare, 
 the tenderness and pain are located near the head 
 of the fibula and back of the joint. 
 
 When a sprain of the knee has been neglected or 
 
 I 2 
 
116 SPRAINS IN THE REGION OF 
 
 improperly treated, stiffness and weakness are the 
 predominant after-effects. When there is much 
 atrophy of the quadriceps extensor muscle and of 
 the gluteus maximus and tensor fasciae femoris, the 
 capsule loses its proper support and sags. Even 
 a slight strain to such a knee is sufficient to cause 
 a copious effusion into the synovial cavity. To this 
 chronic and relapsing condition the name of trau- 
 matic hydrops has been given. The frequency with 
 which this form is met with in football players has 
 given to it the popular name of ' footballer's knee '. 
 In old people sooner or later these chronically 
 distended joints are followed by symptoms of 
 osteo-arthritis. 
 
 Treatment. In all cases of acute traumatic syno- 
 vitis of the knee the patient should be confined to 
 bed. Elastic pressure if immediately applied will 
 relieve pain, arrest and diminish the effusion, and 
 hasten absorption. Slight active movements in the 
 toes and ankle may be commenced from the first ; 
 massage and passive movements not before the 
 effusion has disappeared. Speaking generally, the 
 quickest recoveries follow those cases that are seen 
 early and in which the modern and rational treat- 
 ment is begun from the first and carried out by the 
 surgeon himself until all symptoms have disappeared. 
 
 Given a young healthy individual, he should be 
 perfectly able to resume all his athletic exercises in 
 three weeks. 
 
 In the chronic and relapsing forms often the best 
 line of treatment is to bring about an acute attack 
 by forced movements and manipulation under an 
 anaesthetic, then to employ the rational regime as 
 
THE KNEE-JOINT 
 
 117 
 
 if the joint was being treated for a first attack. 
 Massage may be needed for a considerable time and 
 should be continued until the muscles quite regain 
 
 Fig. 34. Acute traumatic synovitis of the left knee-joint as result of 
 displacement of the external semilunar cartilage. The swelling came on 
 gradually, though quickly. The photograph was taken two hours after the 
 accident. Note the slightly flexed position of the joint, and its general en- 
 largement, with loss of anatomical detail when compared with its neighbour. 
 
 their strength. During all this time a non-elastic 
 bandage may be worn for support. As soon as it is 
 safe the bandage should be discontinued at night, 
 
118 
 
 SPRAINS IN THE REGION OF 
 
 and only used when support is actually needed. 
 The wearing of a bandage, although of some slight 
 support, will not be of itself sufficient to prevent 
 recurrent injury; its presence, however, serves 
 
 Fig. 35. To illustrate the appearance of a knee-joint, the subject of 
 a chronically thickened synovial membrane. The outlines of the capsule 
 may be clearly noted, while the dimplings of the skin and the fossae 
 around the joint are not obliterated as they would be in cases of synovitis 
 with effusion. It will be well to compare with Figs. 33 and 34. 
 
 admirably the purpose of a ' gentle reminder ' ; 
 indeed, by some surgeons it is recommended more 
 for the latter purpose. The method advocated for 
 developing and restoring the wasted muscles is 
 treated of in the chapter dealing with massage and 
 movements. 
 
THE KNEE-JOINT 119 
 
 Sprains in which the Internal Lateral 
 Ligament is most concerned 
 
 The internal lateral ligament is, of all the struc- 
 tures of the knee, that most frequently affected 
 by twisting and wrenching forms of violence. Nor 
 is this surprising, if its situation and attachments 
 are considered. Though a very strong band, and 
 capable of resisting a great amount of strain, it is 
 the main support of the inner side of the joint, so 
 that every stretching force applied to the outer 
 side of the articulation makes its impression upon 
 it. It most generally suffers when the limb being 
 in the extended position is forcibly made to assume 
 or approach the condition of genuvalgum. Any 
 forcible separation of the head of the tibia from the 
 internal condyle puts its fibres upon the stretch, 
 and according as the degree of separation is little 
 or great, stretching or laceration results. 
 
 Sprains of the internal ligament are exceedingly 
 common amongst athletes. Football accounts for 
 the greater number ; but it is met with in players 
 of every sort of game and pastime. The part of 
 the structure which most readily tears is its attach- 
 ment to the femur. Next in frequency are the 
 deep fibres which are attached to the capsular 
 ligament and internal semilunar cartilage. The 
 lower or tibial attachment in the writer's experience 
 is rarely torn. 
 
 Symptoms. If the sprain has been slight, the 
 patient will probably complain of pain located over 
 the whole of the inner side of the joint, increased by 
 every movement whether of flexion or extension. 
 
120 SPRAINS IN THE REGION OF 
 
 There may be nothing to be seen on inspection. 
 Effusion in such a mild case rarely follows if the 
 joint is a healthy one, but even a slight injury may 
 produce it in one previously damaged. 
 
 When, however, the force has been sufficient to 
 produce laceration, the pain is very often consider- 
 able at first, lessening gradually later. It is usual 
 to find an intensely painful spot of small size either 
 just over the upper attachment of the ligament to 
 the inner side of the condyle, or exactly opposite 
 the middle of the border of the semilunar cartilage. 
 In most cases it is in the former situation. The 
 swelling is small and localized at the painful spots 
 above mentioned, and is due to haemorrhage from 
 tearing of a small blood-vessel. 
 
 . If the case is seen early there may be no effusion 
 into the capsule, but this will invariably come on 
 a few hours later. If there is immediate effusion 
 into the joint, it is due to haemorrhage, and results 
 from tearing of the capsule and synovial membrane 
 as well as the lateral ligament. 
 
 When the pain is localized at the level of the 
 semilunar cartilage, especially when there is swelling 
 from extravasation of blood, the case may be, and 
 often has been, mistaken for a detachment with 
 displacement of the cartilage. To the clinical im- 
 portance of this fact reference will again be made 
 in the chapter dealing with displacements of the 
 internal semilunar cartilage. 
 
 In addition to the pain and swelling, it will be 
 noticed that the limb assumes the semiflexed posture, 
 the patient is unable to extend the joint without 
 considerable pain, or to bear any weight on the limb. 
 
THE KNEE-JOINT 121 
 
 Diagnosis. The history of the injury, direction 
 of the force, a feeling perhaps of something snapping 
 or tearing at the time of accident, taken together 
 with the localized pain and swelling already referred 
 to, and the absence of immediate effusion into the 
 capsule, will go far to establish a diagnosis. Rupture 
 of the deep fibres, or separation of them from the 
 internal semilunar cartilage, followed as it invariably 
 is by localized swelling situated exactly over the 
 line of the cartilage, is recognized by the absence 
 of the other symptoms of slipped-cartilage. When 
 in doubt, the patient should be completely anaesthe- 
 tized and an attempt made to reduce the suspected 
 displacement. If such an attempt at reduction is 
 made by the manoeuvre described elsewhere (p. 140) 
 for the reduction of a displaced cartilage proves 
 a failure, it is to be assumed that there is nothing 
 capable of reduction, and that the swelling repre- 
 sents a blood-clot and not a projecting cartilage. 
 Later in the case, the usual play of colours will 
 demonstrate the locality of the effusion and give 
 a fair estimate of its amount. 
 
 The treatment is by elastic pressure and move- 
 ments, the details of which are described in chapter ii, 
 p. 22, et seq. 
 
 Sprains ix which the External Lateral 
 Ligaments are most concerned 
 
 The external lateral ligaments are much less fre- 
 quently injured than the internal. The stretching 
 force necessary has to be applied to the inner side 
 of the joint while it is extended, and, from the very 
 nature of things, as one might expect, is not of 
 
122 SPRAINS IN THE REGION OF 
 
 common occurrence. When the external lateral 
 ligaments yield there is generally considerable ten- 
 derness over the popliteus muscle and at the back 
 of the joint, as well as over its lower attachment 
 to the head of the fibula. Association football 
 players may overstrain or rupture their external 
 ligaments, when they cross legs with one another 
 in kicking at the ball from different directions at 
 the same time, each falling with his leg across that 
 of his opponent. Effusion may or may not take 
 place into the synovial cavity. The diagnosis pre- 
 sents no special difficulty, and the prognosis and 
 treatment is the same as for ordinary sprains of 
 the knee. 
 
 Separation of the body of an internal semilunar 
 cartilage from the deep fibres of the internal lateral 
 ligament of the joint. It sometimes happens that 
 as the result of a sprain the deep fibres of the internal 
 lateral ligament of the knee become separated from 
 their attachment to the convex border of the internal 
 semilunar cartilage. When this occurs haemorrhage 
 follows and the blood clotting in this situation gives 
 rise to a definite localized swelling often readily pal- 
 pable. On several occasions this swelling would 
 seem to have been mistaken for displacement of the 
 cartilage from the joint. Not infrequently when the 
 violence is sufficient to lacerate the synovial mem- 
 brane as well, bleeding into the joint results. It is 
 quite conceivable that a portion of the blood-clot 
 insinuating itself between the cartilage and the tibia 
 on the one side and between the cartilage and the 
 condyle of the femur on the other, becoming organ- 
 ized might produce a definite form of internal 
 
THE KNEE-JOINT 123 
 
 derangement. The writer has seen such a condition 
 of things when operating on a supposed case of 
 displaced cartilage ; and although there was no 
 definite displacement of the cartilage found, the 
 organized blood-clot had so passed between the 
 bones that extension of the knee was impossible, 
 and explained why every previous attempt at 
 reduction by manipulation had failed. 
 
 Sir Wm. Bennett ^ describes a somewhat similar 
 condition as giving rise to the same train of symp- 
 toms, but he attributes the cause to a bruising of 
 the cartilage. It is here maintained that it is 
 generally due to a laceration of the deep fibres of 
 the internal lateral ligament and not always to mere 
 bruising of the edge of the cartilage. 
 
 1 Internal Derangements of the Knee-joint. Longmans, Green 
 & Co., 1903. 
 
CHAPTER VI 
 
 INTERNAL DERANGEMENTS OF THE 
 KNEE-JOINT 
 
 ' Displaced Semilunar Cartilage,' ' Subluxation,' 
 ' Slipped Cartilage,' are terms used synonymously 
 for a strain to which the knee is liable. It is usually 
 the result of sudden violence in the form of a wrench 
 or twist whereby the attachments of one or other 
 semilunar cartilage becomes unduly stretched or 
 torn. A cartilage may, however, become so extremely 
 movable from a gradual stretching of its ligaments as 
 to be caught between the bones even during ordinary 
 movements. It is more common in males, and 
 may occur at any period between the ages of twelve 
 and sixty ; before or after these periods it is almost 
 unknown. 
 
 When the ligaments are extensively torn, and the 
 movements proportionately free, the cartilages are 
 often dislocated inwards into the joint and come to 
 lie in the space between the femoral condyles. More 
 rarely they are displaced outwards. The writer has 
 never met with a case of typical outward displace- 
 ment, although such cases are on record. 
 
 Not only are the ligaments liable to stretching 
 and laceration, but the cartilage itself may be torn 
 across partially or completely {vide Fig. 36). When 
 the tear is complete, the detached portion is liable 
 to be caught and squeezed between the bones. 
 
DERANGEMENTS OF KNEE-JOINT 125 
 
 Lacerations have been met with in almost every 
 part of the cartilages, but the tearing for the most 
 part occurs towards the anterior extremity, for not 
 only is this the weakest part anatomically, but it is 
 also the portion most liable to strain. 
 
 From an examination of many sprains, and from 
 his operative experiences, the writer has formed the 
 
 Fig. 36. The anterior half of an internal semilunar cartilage of the 
 knee removed by operation for partial detachment and chronic synovitis. 
 The larger end is posterior ; the specimen was cut from the posterior 
 fixed portion. Note the thinning out and internal projection of the inner 
 margin of the cartilage. This thin margin when caught between the 
 bones, which was frequent, accounted for the occasional sudden pain and 
 the synovitis. The coronary ligaments had been torn, but the anterior 
 horn remained attached in the intercondyloid space. 
 
 opinion that the most common site for the cleavage 
 to take place is at a point just in front of the junction 
 of the anterior and middle thirds of the internal 
 cartilage, and not at the anterior extremity, as is 
 often stated. The anterior third is the most movable, 
 as well as the most attenuated part of the structure, 
 and being stretched during every movement of 
 
126 INTERNAL DERANGEMENTS OF 
 
 flexion and rotation, readily becomes loose. When 
 actual loosening once takes place, every movement 
 of flexion and rotation tends still further to stretch 
 or undo the coronary attachments ; eventually, by 
 some sudden or exce^ive violence, the cartilage 
 
 Fig. 37. Photograph of the anterior half of a left internal semilunar 
 cartilage removed by operation. The horizontal portion represents the 
 anterior third of the structure which had become detached from the 
 coronary ligaments at its periphery, but remained attached at its anterior 
 cornual site. The vertical limb represents the posterior part of the cartilage, 
 while the angle between them demonstrates admirably the author's observa- 
 tion that the usual site for laceration of a cartilage is near this point, viz. 
 the junction between the anterior and middle thirds, and not, as generally 
 supposed, at the anterior cornual attachment. The patient, who formerly 
 was unable to take any exercise, is now able to do anything and to play 
 at any violent game, for the detached portion, which was wont to fall 
 between the bones during rotation, has been removed. 
 
 already loosened at its anterior border slips back- 
 wards into the inter-condyloid space and escapes for 
 a time, or it may then and there be completely torn 
 across. 
 
 The photograph here depicted is of the anterior 
 half of an internal semilunar cartilage removed 
 recently. It had not been ruptured, but was loosened 
 
THE KNEE-JOINT 127 
 
 from the tibia in its anterior third owing to tearing 
 of the coronary ligaments. 
 
 This specimen was obtained from the knee of an 
 undergraduate, aged twenty, who, in October 1907, 
 for the first time, while ' scrumming ' at football, 
 slipped his cartilage. Between that date and the 
 time of operation in March there had been four 
 distinct recurrences ; indeed, no sooner had the 
 symptoms disappeared under treatment and the 
 patient begun to walk about, than some trivial 
 movement, such as getting in and out of his bath, 
 was enough to disable him. Each relapse seemed 
 more easily produced than the former one, while the 
 ' cure ' took longer each time. 
 
 Growing weary of the inconvenience he decided 
 to have the cartilage removed. 
 
 An examination of the specimen shows distinctly 
 the acute angle formed between the anterior movable 
 part and the posterior fixed portion. The longer 
 limb in the picture represents the anterior, the 
 shorter the posterior, where it was cut from the 
 hinder part of the cartilage during its removal. 
 
 The anterior limb was directed inwards from its 
 anterior attachment to the inter-condyloid notch, in 
 which situation it was seen to lie while the limb 
 remained in the extended position. While the joint 
 remained open, so that observations could be made, 
 and the knee was flexed and the leg rotated out- 
 wards, this movable portion shifted its position and 
 was brought to lie between the femur and tibia, and 
 so caught that extension was rendered impossible. 
 
 During the last twelve months the writer has 
 operated on four cases in which rupture, partial or 
 
128 INTERNAL DERANGEMENTS OF 
 
 complete, had taken place at the spot above indi- 
 cated. He has also at different times seen cases 
 illustrating the successive stages from the first 
 loosening of the cartilage from its^ anterior coronary 
 attachments to its complete displacement between 
 the condyles of the femur, and so on to that of par- 
 tial and even complete fracture with displacement. 
 The photograph shows a cartilage with partial 
 detachment at the angle of the junction between the 
 anterior and middle portions. In this particular 
 instance a rare opportunity was afforded of studying 
 the mechanism of a knee-joint in which the anterior 
 portion of an internal semilunar cartilage was not 
 only movable, but became displaced and caught, in 
 certain movements of the joint. When ordinary 
 flexion and extension were executed slowly and with- 
 out any, or with very little, rotation in a passive 
 way by the operator (the patient being under an 
 anaesthetic), the cartilage remained displaced into 
 the inter-condyloid notch and was not caught between 
 the bones ; but whenever the movements were 
 rapidly executed and considerable rotation allowed, 
 it became nipped between the femur and tibia, so 
 that the joint was locked and complete extension 
 made impossible. The inner margin of the specimen 
 shown in Fig. 36 shows a thinning out from its 
 being frequently nipped between the femoral condyle 
 and the tibia. 
 
 On rare occasions the cartilage is split longi- 
 tudinally instead of across. The writer has met with 
 a case in which an internal cartilage was partially 
 torn into three strips at its anterior two-thirds, so 
 that the two inner portions were flattened out and 
 
THE KNEE-JOINT 
 
 129 
 
 loose. The most internal strip had been completely 
 detached posteriorly, and passing inwards between 
 the bones was doubtless the cause of the symptoms. 
 The cartilage itself remained intact at its posterior 
 third, and was firmly fixed to the tibia both by its 
 
 Fig. 38. Drawing from a specimen of an internal semilunar cartilage 
 of the knee, showing longitudinal splitting into three strips in its anterior 
 half. The narrow part is posterior. The cartilage was much broader 
 than normal, and while attached at its usual site anteriorly the innermost 
 strip became detached posteriorly and, as indicated by the dotted Une, 
 was wont to shp inwards into the joint and get caught between the bones. 
 The details of the case are given in the text. 
 
 posterior cornu and coronary ligaments. The accom- 
 panying drawing is meant to convey roughly some 
 idea of the appearance of the specimen, which unfor- 
 tunately was torn by a bystander before it had been 
 photographed. The patient was a man of thirty- 
 five who, from the age of twelve, had worked in 
 
 WHTTELOCKE 
 
 K 
 
130 INTERNAL DERANGEMENTS OF 
 
 a coal mine. He stated that when he was about 
 fifteen he strained his knee and was laid up for 
 nearly a year off and on, but that he afterwards 
 became quite well and able to do his work, although 
 often stiff when he first began work each morning. 
 The joint at times would swell considerably, and, as 
 far as he could remember, he was never able to 
 straighten it completely. This did not inconvenience 
 him in the mine, for, as he said, he was generally 
 lying on his side, or squatting, while at work. It 
 was only when he went for a long walk on Sundays 
 that the joint would swell and ' bother '. There was 
 always some ' clicking ' or ' creaking ' when the joint 
 was worked ; this both he and the colliery doctor 
 attributed to rheumatism. Shortly before he sought 
 advice he one day ran after a dog, and, in trying to 
 kick it while standing on his weak leg nursing his 
 knee, he wrenched the joint and ' felt something go ' 
 with a ' snap ', became powerless from pain, felt 
 sick, and fell to the ground. There was some evi- 
 dence of old osteo-arthritic changes in the joint. 
 The rarity of these cases of longitudinal splitting, 
 together with the interesting history given by the 
 patient, the writer considered sufficient to warrant 
 a detailed account. 
 
 The anterior two-thirds of the cartilage was 
 removed by the method of operating to be described 
 later, the patient made a complete recovery, and 
 resumed work at a colliery eight weeks after. He 
 has since gone on well, suffering in no way from the 
 osteo-arthritic changes which had already begun at 
 the time of the operation. 
 
 The internal cartilage is much more frequently 
 
THE KNEE-JOINT 
 
 131 
 
 injured than the external. Various factors are con- 
 cerned in this. First and foremost it may be stated 
 that the internal cartilage does not enjoy the same 
 range of movement as its fellow, while at the same 
 
 A.C.L 
 
 UPPER SURFACE 
 
 INT.S.C. 
 
 P.C.L. 
 
 Fig. 39. Drawing made from the upper sm-face of the head of a left 
 tibia, to indicate by the dotted lines the anatomical relationships of the 
 semilunar cartilages one to the other, and to demonstrate their precise 
 points of attachment, as well as the relative positions of the attachments 
 for the anterior and posterior crucial ligaments. 
 
 A.C.L. = Anterior crucial ligament. 
 
 P.C.L. = Posterior crucial ligament. 
 
 EXT.s.c. = External semilunar cartilage. 
 
 iNT.s.c. = Internal semilunar cartilage. 
 
 time a greater strain is put upon it during the 
 
 ordinary movements of the joint. 
 
 The external semilunar cartilage is more circular 
 
 in shape, forms the arc of a smaller circle, while its 
 
 cornual attachments, both before and behind, are 
 
 embraced by those of the internal. This gives it 
 
 k2 
 
132 INTERNAL DERANGEMENTS OF 
 
 a greater degree of mobility whereby it escapes to 
 a greater extent the grinding strain of the condyle 
 upon the tibia during the movements of rotation. 
 
 The range of movement of the internal cartilage 
 is furthermore limited by its attachment to the 
 capsular and internal lateral ligaments. The external 
 cartilage is not attached to the long external lateral 
 ligament, and although its border is grooved by the 
 popliteus tendon, it does not seem to derive much 
 support from it. Again, if we compare the anatomy 
 of the cartilages themselves, the reason is at once 
 forthcoming. 
 
 The semilunar cartilages may be regarded as the 
 remains of what were originally two complete disks 
 interposed between the surfaces of the femur and 
 tibia. By the process of time these disks have been 
 so worn away in certain localities as to become much 
 thinned and assume a semilunar shape. The wearing- 
 away process has progressed to a greater extent 
 towards the interior of the joint, so that the carti- 
 lages, originally of equal thickness throughout, now 
 come to possess a thin edge directed towards the 
 tibial spines, and a thicker border or base towards 
 the periphery. 
 
 As the strain in all the ordinary movements of 
 the joint is greater on the inner than the outer side, 
 it follows that the internal cartilage becomes more 
 worn away than its fellow, and for the same reason 
 the anterior segment of the internal cartilage is 
 more attenuated and narrower from side to side, 
 than any other portion of either cartilage. 
 
 The fact also that the anterior portion of the 
 internal cartilage is the most attenuated explains not 
 
THE KNEE-JOINT 133 
 
 only its inferior strength as compared with the other 
 parts of those structures, but materially influences 
 its mode of attachment anteriorly. 
 
 The horns of both cartilages are attached to the 
 tibia anteriorly and posteriorly, and it is necessary 
 that attention should be drawn to the precise nuodes 
 of attachment. 
 
 The anterior horn of the internal cartilage is 
 attached in front of the internal tibial spine and 
 immediately in front of the anterior crucial ligament, 
 whilst its other end is fixed to the tibia in front of 
 the posterior crucial ligament. 
 
 The anterior horn of the external cartilage finds 
 attachment in front of the external tibial spine and 
 behind the anterior crucial ligament, whilst its pos- 
 terior cornu is bound down to the rough space 
 between the tibial spines in front and to the outer 
 side of the attachment of the internal cartilage. It 
 will be seen that the posterior horns of both cartilages 
 are firmly attached to the tibia, while the external 
 cartilage receives in addition a strong fasciculus from 
 the posterior crucial ligament, as well as an occasional 
 slip (Poirier) which passes from its outer and posterior 
 surface to be attached to the outer surface of the 
 internal femoral condyle. 
 
 The anterior horn of the external cartilage is 
 firmly attached to the tibia, and is a structure of 
 considerable strength, while the anterior horn of the 
 internal cartilage varies greatly as to its strength 
 and precise mode of attachment. 
 
 It not infrequently happens that the anterior horn 
 of the internal cartilage is very attenuated and may 
 be attached 
 
134 INTERNAL DERANGEMENTS OF 
 
 (1) to the periosteum in front of the upper tibial 
 
 border ; 
 
 (2) to the anterior border of its neighbouring 
 
 semilunar cartilage, taking, as it were, the 
 place of the transverse ligament; 
 
 (3) to its usual site by very feeble ligamentous 
 
 union. 
 
 When such an enfeebled development of the carti- 
 lage exists there is a strong predisposition to its 
 displacement, and this fully explains why the internal 
 is so much more frequently displaced than the ex- 
 ternal cartilage. The main body of each cartilage is 
 fixed to the upper margin of the tibia and held firmly 
 in position by the coronary ligaments. The internal 
 cartilage also derives firm attachment at its inner 
 border or base, especially at its middle portion, from 
 fibres both from the capsular ligament and the 
 deep fibres of the internal lateral ligament of the 
 joint, while the external receives no corresponding 
 reinforcement. 
 
 The reinforcing fibres from the deep portion, or as 
 it is sometimes described, the deep internal lateral 
 ligament, are, as we said previously, and as we shall 
 see again later when treating of a special sprain of 
 the knee in which they are mainly concerned, of 
 very great surgical and clinical importance. 
 
 In certain cases the body of the cartilage becomes 
 separated from its coronary and capsular attach- 
 ments, although the cornual attachments remain 
 intact. 
 
 ' The only common form of displacement, how- 
 ever, is that in which the anterior part of the internal 
 cartilage is torn away from its tibial attachment or 
 
THE KNEE-JOINT 135 
 
 from the transverse ligament, and finds its way into 
 the joint between the bones ' (Rawling).^ The free 
 end is Hable to be caught and even ruptured during 
 the ordinary movements. 
 
 The writer has observed the following changes as 
 taking place in the detached portion : sometimes 
 it becomes flattened out and fibrous, or contains 
 calcareous deposit, at others bulbous and thickened, 
 but in most instances, and except in those of very 
 long standing, it retains to a remarkable degree its 
 elasticity and truly cartilaginous appearance. 
 
 When detached, these portions may even increase 
 in size and present a smooth polished surface. 
 
 Symptoms and Clinical Characteristics 
 
 The advice of the surgeon may be sought either 
 at the occurrence of the first disaster or later, after 
 many recurrences. 
 
 The history is usually a very definite one. The 
 patient, while playing at some game, or as the result 
 of a sudden and violent movement, is seized with 
 pain, often so intense as to cause him to fall to the 
 ground in a fainting condition. There may have 
 been a sensation as of something having given way, 
 and a distinct click or crack may have been heard, 
 and if the cartilage remains nipped between the 
 bones, the limb may become ' locked ' in a slightly 
 flexed position. So long as the displacement remains, 
 the position is always one of slight flexion \ complete 
 extension is impossible and painful, while full flexion 
 
 1 L. B. Rawling, 'Displacement of the Internal Semilunar Cartilage 
 of the Knee-joint.' Practitioner, September, 1907, p. 358. 
 
136 INTERNAL DERANGEMENTS OF 
 
 is usually comparatively easy and almost painless.. 
 If pressure is made over a point corresponding to the 
 anterior attachment of the cartilage, i.e. in the line 
 between the bones close to the ligamentum patellse, 
 acute tenderness will be complained of. 
 
 Sometimes spontaneously, at other times by the 
 assistance of a bystander, the cartilage slips from its 
 position between the bones, returns to its natural 
 position, full extension is permitted, and the patient 
 may even be able to walk, though lamely. Palpa- 
 tion, as a rule, is of very little assistance in making 
 a diagnosis, for owing to the tenderness which is 
 usually present, the patient objects to its practice ; 
 and as the cartilage, in the very great majority of 
 cases, is displaced inwards towards the joint, it 
 cannot be felt. Considerable effusion rapidly inter- 
 venes, and in the space of a few hours the capsular 
 ligament may be distended to its fullest capacity, 
 and the patient thereby confined to his sofa perhaps 
 for weeks. In course of time, especially if treated 
 by rest, massage, and early movements, he may make 
 a complete recovery. As a rule, however, when the 
 displacement results from much tearing of the liga- 
 ments of the cartilage, or when the cartilage itself 
 has been torn across, recurrences may be expected. 
 These repeated attacks are liable to occur at any 
 time, causing much inconvenience, and in the worst 
 cases may even lead to disorganization of the articula- 
 tion and permanent disablement. 
 
 In the recurrent displacements the symptoms are 
 of a similar nature, though they may not always be 
 of equal severity. The patient usually learns some 
 dodge or particular manoeuvre for reducing the dis- 
 
THE KNEE-JOINT 137 
 
 placement. Sooner or later the joint becomes 
 weaker, little or no reliance can be placed upon it, 
 it slips out at the most inopportune moments, so 
 that the subject may neither be able to enjoy life 
 nor earn his livelihood. He then seeks the advice of 
 a surgeon, or perhaps a bone-setter, as to the means 
 whereby the displacement may be prevented and 
 the joint restored to its former strength. 
 
 There is a prevalent idea amongst surgeons, and 
 not apparently without reason, that osteo-arthritic 
 changes are liable to follow on these repeated attacks 
 of acute recurring synovitis. 
 
 The prognosis of recurrent displacements is there- 
 fore far from good, and steps should be taken in 
 every case to prevent them either by palliative or 
 curative means. 
 
 Diagnosis. The differential diagnosis has to he 
 made from 
 
 (1) sprains of the lateral ligaments of the knee; 
 
 (2) loose bodies in the joint, whether free and 
 
 unattached or pedunculated and attached ; 
 
 (3) thickened outgrowths and hypertrophied fringes 
 
 of the synovial membrane ; 
 
 (4) partial separation of the internal cartilage from 
 
 the deep portion of the internal lateral liga- 
 ment of the joint. 
 An inquiry into the history of the case, and the 
 exact site of greatest tenderness, will often be of 
 assistance in differentiating between these varied 
 conditions. 
 
 In the case of a displaced cartilage the pain is 
 always referred to the same spot, while in other loose 
 bodies it may be at any part of the joint, and varies 
 
138 INTERNAL DERANGEMENTS OF 
 
 in intensity from time to time. Thickened synovial 
 fringes and outgrowths, when they become caught 
 between the bones, so closely simulate a movable 
 cartilage that a correct diagnosis is impossible with- 
 out opening and exploring the joint. Detachment 
 of the internal lateral ligament from the cartilage 
 gives rise to a painful swelling situated immediately 
 over the middle of the basal border of the cartilage, 
 coming on soon after the occurrence of the injury, 
 and due to haemorrhage. Palpation will elicit a boggy 
 swelling, tender to the touch, liable to increase from 
 subsequent inflammatory changes, and followed some 
 days later by the usual signs of bruising — play of 
 colours. The characteristic locking may be absent, 
 though complete extension will be impracticable. 
 
 The determining cause of a displacement is usually 
 some sudden twist or screw action of the body while 
 the leg remains firmly planted on the ground. It 
 can only occur when the limb is to some degree 
 flexed. When the femur is forcibly rotated outwards 
 on the tibia the internal condyle is brought into 
 intimate contact with the anterior extremity of the 
 cartilage and puts it on the stretch. If the stretching 
 force is great or sudden it is quite easy to understand 
 how the cartilage may be torn at its weaker anterior 
 attachment, and in this way become displaced. 
 Various forms of athletic exercises predispose to the 
 injury : football, skating, lawn-tennis, cricket, and 
 other games afford numerous opportunities. ' Scrum- 
 ming ' at Rugby football, whereby the feet are firmly 
 planted on the ground and, while the knees are semi- 
 flexed, the body is made to swing forcibly to one or 
 other side, is eminently suitable. Figure-skating, 
 
THE KNEE-JOINT 139 
 
 where the performer swings quickly round and pushes 
 off with the foot is often a cause. It occurs more 
 frequently in the left knee than in the right, as most 
 sudden movements are made from right to left, so 
 that greater strain is put upon the left knee.-^ 
 
 Treatment of the first attack is for convenience 
 divided into two stages : — 
 
 (1) The immediate, or reduction of the displaced 
 cartilage ; 
 
 (2) The subsequent treatment. 
 
 Various methods and devices have been adopted 
 for the reduction of a fixed cartilage, some employed 
 by the profession, others by the patients themselves. 
 
 Amongst them may be briefly noticed that of 
 alternately flexing and extending the joint, com- 
 bining with these the movements of rotation. 
 Though often successful, this is by no means a 
 reliable plan, and is the method generally adopted 
 by bystanders and others. 
 
 Another means, which involves practically the same 
 principles as the last, is that to which some years ago 
 the writer himself drew attention in a paper,^ as 
 having been first suggested to him by a master at 
 one of the famous public schools. It consists in 
 making the patient, when it is possible, engage in 
 swimming. The alternate flexion and extension, 
 together with the amount of rotation involved in 
 the act of swimming, is all that is necessary to effect 
 reduction. It is a simple and generally effective 
 
 1 Sir William Bennett, K.C.V.O., Internal Derangements of the 
 Knee-joint (Longmans, Green & Co.), p. 74. 
 
 2 Football Injuries, by R. H. Anglin Whitelocke, M.D., F.R.C.S. 
 (Churcliill), 1904. 
 
140 DERANGEMENTS OF KNEE-JOINT 
 
 device, but as it is not often that a swimming-bath 
 is at hand, and as many persons are unable to swim, 
 it is more convenient to place the patient prone upon 
 the floor and instruct him to imitate the movements 
 of swimming. It has been a matter of surprise to 
 the writer how very generally successful the practice 
 is. The patient, often amused and not a little 
 curious, strikes out vigorously, takes his muscles 
 unawares, as it were, and succeeds at the very first 
 attempt in completely extending the joint. 
 
 It has been considered useful to refer in this place 
 to such a plan, for these accidents occur at such 
 unexpected times and in such inconvenient places 
 that skilled assistance may not be forthcoming. A 
 patient, the subject of recurrent attacks, is thus 
 enabled to help himself early in the case, and gain 
 much time in starting the subsequent treatment. 
 
 The method which for some years has been in- 
 variably practised by the writer, and which is based 
 upon anatomical considerations, is here illustrated, 
 for the sake of clearness, by photography. It is a 
 plan which is not only safe but convenient, is 
 suitable for longstanding displacements as well as 
 recent, and when properly carried out seldom fails. 
 
 It consists in making the patient, his clothing 
 having been sufficiently removed, lie flat upon the 
 floor or some low couch or bed. The surgeon then, 
 standing on his outer side, flexes the leg upon the 
 thigh and the thigh upon the body as much as is 
 possible. The flexed knee is then adducted so as to 
 cross the middle line of the body and come to lie 
 across the navel. In this position the hamstring 
 muscles as well as the extensors of the thigh are fully 
 
Figs. 40, 41, 42 illustrate the author's method of reducing displacements 
 of the semilunar cartilages of the knee. 
 
 Fig. 40. The posture assumed by a knee in which the cartilage has 
 not been reduced and is still out. 
 
 Fig. 41. First position of flexion of knee and hip joints. 
 
 Fig. 42. Second position of complete flexion with adduction across 
 line of the body, vide text. For the sake of clearness tjie operator is hei'e 
 depicted as standing on the inner instead of the outer side of his patient. 
 
142 INTERNAL DERANGEMENTS OF 
 
 relaxed, while the internal and external lateral liga- 
 ments of the knee are in their slackest state. The 
 surgeon then grasps with the one hand the lower end 
 of the femur just above the knee, and with the other 
 the region of the ankle, and while keeping the 
 patient's thigh in the fully flexed position with the 
 aid of his own knee, he abducts the leg from the thigh 
 so that the greatest possible interval is allowed be- 
 tween the internal condyle and inner tuberosity of 
 the tibia. In many instances when this stage has 
 been reached the surgeon's hand grasping the knee 
 may experience a sensation as if something slipped 
 beneath it, or he may hear a click, a snap, or other 
 noise indicative of the movements of the cartilage. 
 In most cases this looked-for result does not arrive 
 until after the next stage, that of rotating the tibia 
 upon the femur first internally and then externally, 
 followed by a smart and sudden extension of the limb. 
 When the reduction has been effected the limb at 
 once becomes capable of complete extension and the 
 patient experiences immediate relief. 
 
 The surgeon must not be satisfied until the exten- 
 sion is as complete as in the other knee. In recent 
 cases an anaesthetic is rarely needed, as the manoeuvre 
 is not painful and patients usually readily submit to 
 it. In women, for other and obvious considerations, 
 it may be better to administer an anaesthetic. 
 
 In longstanding cases, where the inability has 
 existed for weeks and even months, and where sub- 
 sequent inflammatory changes have taken place or 
 are suspected, an anaesthetic, besides rendering the 
 manipulation simpler, will enable the surgeon to 
 make a more complete examination and satisfactory 
 
THE KNEE-JOINT 
 
 143 
 
 differential diagnosis. If it should happen that one 
 or two attempts fail, in a recent case, an anaesthetic 
 should be administered, and an attempt made to 
 
 A B 
 
 Fig. 43. a and b are schemes to illustrate further the author's method. 
 The arrowheads indicate the directions in which the leg is moved or swung 
 is disengaging a locked cartilage. In scheme b the operator's right hand 
 should be placed on the lower thigh instead of on the head of the tibia. 
 
 decide once and for all whether it is a case of ' slipped 
 cartilage' proper, or one of hypertrophied syno- 
 vial fringes or other condition giving rise to a some- 
 what similar train of symptoms. 
 
144 INTERNAL DERANGEMENTS OF 
 
 When reduction by manipulation is impossible, 
 even with the aid of an anaesthetic, it will be neces- 
 sary to open the joint and remove the cause. The 
 details of such an operation will be considered later. 
 
 2. Subsequent treatment. As soon as the carti- 
 lage is replaced means should be adopted to check 
 as much as possible the outpouring of serous effusion 
 into the capsular cavity. The success or otherwise 
 in preventing or limiting the effusion will depend 
 upon the length of time that has elapsed before the 
 patient comes under proper surgical treatment, and 
 to the amount of rule-of -thumb assistance or violence 
 rendered by bystanders or officious friends. These 
 persons, with the best intentions in the world, often 
 contribute unconsciously to the seriousness of the 
 case. When seen soon after reduction, the patient 
 should be put to bed or confined to a couch. To 
 check effusion and to facilitate its absorption, 
 nothing is of greater service, or indeed as useful, as 
 the method already described as applicable to all 
 sprains with effusion, namely, elastic pressure with 
 the aid of a pad of cotton-wool and tight bandage. 
 This application enables the knee to assume the 
 posture of greatest repose^that of semi-flexion — 
 whereby the pain is diminished. It is sufficiently of 
 the nature of a splint to secure temporary rest, while 
 it can be easily and conveniently removed and re- 
 applied once or oftener during the first few days. 
 
 Treatment by ice-bags and warm applications only 
 delays matters, and does not favourably influence 
 absorption. Nor should any fixed apparatus like a 
 plaster splint be used. Such a knee should be treated 
 in the same way as any other sprained joint, and the 
 
THE KNEE-JOINT 145 
 
 possibility of stiffness arising from the formation of 
 adhesions should always be guarded against. 
 
 The effusion should be absorbed in about a week, 
 and until this has all but disappeared neither massage 
 nor passive movements are of service : on the other 
 hand, active movements of the limb remote from the 
 joint, such as the movements of the ankle and foot, 
 should be encouraged from the very first. These 
 active movements of the muscles of the leg and foot, 
 while putting no strain on the knee itself, influence 
 its nutrition, and prevent anything like muscular 
 atrophy in the muscles acting on the knee. Passive 
 movements may assist in preventing or in stretching 
 newly-formed adhesions in some joints, but in the 
 case of the knee they also must tend to move the 
 cartilages themselves and drag upon their newly- 
 formed attachments, the very thing that we wish to 
 avoid in this particular instance. Passive move- 
 ments cannot prevent atrophy ; they act simply 
 mechanically, never physiologically, and may well 
 be entirely dispensed with in this affection. 
 
 Massage in the early stages is not only unnecessary, 
 but is inferior in its utility as compared with elastic 
 pressure, where rapidity of absorption is the key- 
 note of treatment. Its uses, however, in the later 
 stages of sprain treatment cannot weU be overrated, 
 and the author is second to none in its advocacy 
 when old blood clot and soUd oedema require re- 
 jnoval. After the effusion has disappeared active 
 movements should be daily increased, providing no 
 strain of a rotatory kind is permitted ; a firm domette 
 or crepe-velpeau bandage should be substituted for 
 the wadding, and the patient allowed to get up, but 
 
 WHITELOCKE t 
 
146 INTERNAL DERANGEMENTS OF 
 
 not to walk. The knee should at first be always 
 supported with a firm bandage so applied as to keep 
 the joint still. This may be removed once or twice 
 daily to allow the joint to be massaged, or the whole 
 limb may be rubbed without removing the knee- 
 bandage. Never apply an all-rubber bandage, for 
 they are too powerful; they starve the joint of 
 oxygenated blood, and are often uncomfortable. 
 
 In about a fortnight's time the patient may be 
 permitted to walk, still wearing a bandage. He 
 should be instructed to avoid any movements of 
 rotation, and to keep the foot well turned out. The 
 bandage need not be worn at night after three weeks, 
 but should be re-applied before getting out of bed 
 each day, and worn continually during the day for at 
 least a month or five weeks. 
 
 The bandage will in no way prevent displacement, 
 but acts as a reminder that liberties may not yet be 
 taken, nor violent exercises resumed. 
 
 In a certain small proportion of cases treated by 
 rest, massage, and movements, a complete cure 
 results, but the vast majority become victims to 
 recurrence. 
 
 Many surgeons advocate a prolonged system of 
 treatment by plaster splints and other fixed appara- 
 tus, and while from theoretical considerations this 
 would seem only reasonable and common sense, the 
 writer has been led to believe, after a considerable 
 experience, that the cases treated by the shorter 
 regime and with movements from the first, are, to say 
 the least, no more liable to recurrence. For some 
 reason the re-attachments of a loosened cartilage 
 seldom become firm enough to keep it in place, and 
 
THE KNEE-JOINT 147 
 
 it is possible that a considerable number of cases of 
 ' cure ' have really not been in the first instance true 
 cases of displaced cartilage. The experience of most 
 operators as to the unsatisfactory results of suturing 
 down the cartilages supports this contention. From 
 an examination of many specimens of ruptured or 
 even partially torn cartilages removed by operation. 
 
 Fig. 44. A portion of bone detached from the edge of a patella some 
 years previously. The specimen had become almost entirely covered by 
 hyaline cartilage, which had grown over its fractured edges from the 
 periphery. It is illustrative of the formation of one variety of loose 
 body in a joint, and of the growth of cartilage over detached fragments 
 of bone in joints. About twice its natural size. 
 
 the writer has seldom if ever met with anything 
 giving the definite appearance of an attempt at 
 union. Sometimes one finds the floating end of 
 a detached cartilage bulbous, rounded off, even 
 smoothly polished. The same observation applies 
 to portions of articular cartilages that have become 
 detached by accident. A careful examination will 
 usually show that the once roughened edge or surface 
 
 l2 
 
148 INTERNAL DERANGEMENTS OF 
 
 of such a detached portion is becoming rounded off 
 and covered over with hyahne cartilage. The accom- 
 panying photograph was taken of a specimen from 
 the knee of a gentleman who, two years previously, 
 had been bumped against the edge of a gate by a 
 restive horse while out hunting. He had suffered 
 considerable pain, and had been laid up for some 
 weeks and treated elsewhere. He sought advice 
 because occasionally he experienced sudden pain 
 when mounting his horse, followed by swelling of the 
 joint, never at any other time. This became a 
 nuisance, and he was advised to have his knee ex- 
 plored. When the joint was opened the semilunar 
 cartilages and ligamenta alaria and mucosa were all 
 intact and natural to look at, but the synovial 
 membrane had the appearance of yellow ochre, and 
 some yellow semi-gelatinous material could be ex- 
 pressed from the capsule. 
 
 From the under surface of the outer condyle of 
 the femur was projecting the specimen here figured. 
 It fitted into a depression in the corresponding sur- 
 face of the tibia. On removal it was found to be a 
 piece of bone almost completely enclosed in hyaline 
 cartilage. On the outer edge of the patella was a 
 roughened patch also completely covered with hyaline 
 cartilage from which this piece had evidently been 
 detached two years before. The hyaline cartilage 
 had grown over both the roughened surfaces of the 
 patella and that of its detached fragment, and well 
 illustrates the process of formation of at least one 
 variety of loose cartilage in the knee. Whether this 
 growth of cartilage over the bones is mainly due to 
 the effect of polishing movements, or to some protec- 
 
THE KNEE-JOINT 149 
 
 tive influence exerted by synovial secretions upon 
 detached bodies, it is difficult to give an opinion ; still, 
 the observation is interesting in this relationship. 
 
 Treatment of Recurrent or Relapsing 
 Displacement 
 
 As was stated before, the majority of cases suffer 
 a relapse, and the resulting disability becomes one of 
 serious inconvenience, to say nothing of the risks of 
 permanent disablement to which such a joint be- 
 comes liable, either from its disorganization and 
 ultimate weakening, or from crippling osteo-arthritis. 
 The surgeon has often to decide which is the more 
 suitable line of treatment. If we assume for the 
 moment that the patient has experienced at least 
 one definite recurrence, then two lines of treatment 
 are open to us — ^the one tentative or palliative, the 
 other curative or permanent. 
 
 (1) The palliative is by the utilization of some 
 apparatus as the one figured on p. 150. The essentials 
 of such an appliance are that while it allows freely of 
 flexion and extension of the joint, it prevents or 
 controls rotation of the tibia on the femur. Various 
 instruments have been invented and patented and 
 largely advertised, but they all possess certain 
 serious disadvantages. They are expensive, liable to 
 go wrong, often clumsy and inconvenient, and while 
 they do very well for ordinary walking and gentle 
 exertion, they prevent the wearer from joining in the 
 usual athletic exercises. To young patients they are 
 particularly irksome, and even older ones complain 
 of them, especially when they have to be worn con- 
 tinuously for some considerable period of time. As 
 
150 INTERNAL DERANGEMENTS OF 
 
 by a radical operation the surgeon at the present day 
 is able to dispense with the use of trusses in cases of 
 hernia, so in all probability will he be able, and that 
 before long, to give up recommending trusses and 
 other paraphernalia for the knee-joint in cases of 
 displaced cartilage. 
 
 (2) The operative treatment is, all circumstances 
 considered, more satisfactory in this class of relapsing 
 
 Fig. 45. The block represents a very useful apparatus to be worn by 
 those cases unsuited for operation. It allows of flexion and extension of 
 the joint, but no rotation, so that displacements of the semilunar carti- 
 lages are prevented. The block was kindly lent by Messrs. Lindsey & 
 Sons, instrument makers at Oxford and London. 
 
 cases. A few years ago surgical opinion was about 
 equally divided as to whether or no an operation was 
 advisable ; to-day most surgeons are in favour of it. 
 Many circumstances have been instrumental in bring- 
 ing about this change of opinion, and amongst these 
 may be mentioned the improved technique in all sur- 
 gical procedures, whereby the opening of a knee-joint 
 has been robbed of that unspeakable dread which our 
 forbears seem to have had for it. To-day the modern 
 
THE KNEE-JOINT 151 
 
 surgeon, although fully recognizing the risks of such a 
 proceeding, is able to meet the difficulty with as much 
 equanimity and confidence as he would any other 
 major operation. And not only have the risks of 
 disaster been lessened and almost abolished, but the 
 better understanding of the precise pathology and 
 anatomy of a displaced and torn cartilage has led 
 surgeons to realize that without operation true union 
 is in most cases not to be expected, and that at the 
 best non-operative methods are but tentative. Fur- 
 thermore, it is recognized that removal of the carti- 
 lage, if properly carried out, results in a permanent 
 cure ; so much is this the case that persons who 
 formerly were dismissed the services as suffering 
 from an incurable form of lameness are now, thanks 
 to a skilful operation, enabled to remain. Many 
 athletes have been enabled to resume their former 
 games without any recurrence or any semblance of 
 it. It may be stated generally that here, as in all 
 other serious operations, the pros and cons should be 
 carefully weighed so that none but suitable cases and 
 those likely to be cured should be subjected to 
 operation. 
 
 It may be premised that any operation other than 
 removal of the displaced or free portion is unlikely 
 to succeed. The method of suturing the cartilage to 
 the tibia, as advocated by some writers, invariably 
 fails, and it is difficult to explain why such an opera- 
 tion is still recommended except on theoretical 
 grounds. Every case of this plan of treatment that 
 has been brought under the writer's notice has proved 
 a failure. It is only those parts that are loose and 
 movable that should be removed, and it may be 
 
152 INTERNAL DERANGEMENTS OF 
 
 stated with a degree of confidence that the removal 
 of a portion or the greater part of either cartilage will 
 in no way diminish the usefulness of the joint. 
 Eleven years ago the writer himself removed (at one 
 sitting) portions of one external cartilage and both 
 
 Fig. 46. A recent photograph to illustrate the scars of the trans- 
 verse incisions formerly used by the author. The case is mentioned in 
 the text. At a single sitting portions of both internal and one external 
 semilunar cartilages were removed for displacement more than ten 
 years ago. 
 
 the internal cartilages from a patient, who is now 
 able to ride perfectly and to play polo with great 
 skill. Previous to operation he was unable to walk 
 or take any exercise, as the least movement pro- 
 duced a displacement of one or other cartilage. 
 
 Preliminaries to Operation. Success will depend 
 
THE KNEE-JOINT 153 
 
 upon certain details being carefully and sedulously 
 carried out. First and foremost it is advisable that 
 no operation should be undertaken while signs of 
 serious effusion exist ; it should be postponed, if 
 possible, until all has disappeared. The patient 
 should not be permitted to walk for three or four 
 days immediately preceding the operation, and 
 during this time should be kept resting in bed or on 
 a sofa. Every attention must be paid to cleansing 
 and disinfecting the skin of the knee and adjacent 
 parts, which should also be clean-shaved. The skin 
 of the thigh, knee and leg should be daily washed with 
 a solution of ether soap, followed by antiseptic com- 
 presses, and every means should be taken to secure 
 absolute cleanliness. It is advisable that the surgeon 
 and his assistant should wear sterilized rubber or 
 other gloves, and every means be taken to insure 
 complete asepsis before, during, and after the opera- 
 tion. 
 
 Operation. The limb having been prepared, the 
 surgeon stands on the outer side of the patient with 
 his assistant facing him. The limb is slightly flexed 
 and placed on its outer side, resting on a sandbag or 
 other support. A slightly curved incision is made 
 through the skin and fascia, beginning over the most 
 prominent part of the internal condyle of the femur, 
 and brought downwards and forwards to about three- 
 quarters of an inch from the inner margin of the 
 patella, and then downwards and slightly backwards 
 to the tuberosity and inner surface of the tibia, the 
 lower limb of the incision being made parallel with 
 the anterior portion of the internal lateral ligament 
 {vide photograph). The middle point of the incision 
 
154 INTERNAL DERANGEMENTS OF 
 
 should correspond with the Hne of the joint. The 
 sides of the incision are then retracted, while all 
 bleeding points are carefully secured and ligatured. 
 
 The internal lateral ligament should then be 
 defined and opened somewhat obliquely so as to be 
 exactly parallel with the direction of its fibres. It 
 
 Fig. 47. Incision for exploratory arthrotomy of the knee-joint or for 
 removal of an internal semilunar cartilage. First stage, through the skin 
 and fascia, exposing the internal lateral ligament. In this position (slight 
 flexion of the joint) of the limb the edges of the wound readily fall apart 
 and do not require retraction. 
 
 is customary at this stage to meet with the branches 
 of the upper and lower internal articular arteries. 
 Branches may be seen coursing under the periosteum 
 over the head of the tibia. If not by this time cut 
 across they may be picked up and divided between 
 two pairs of forceps and ligatured. The opening 
 through the internal lateral ligament is best made 
 
THE KNEE-JOINT 155 
 
 three-quarters of an inch from the border of the 
 patella. The cut edges of the internal ligament are 
 now retracted so as to expose clearly the synovial 
 membrane. All bleeding points should be ligatured 
 before the joint is opened. The membrane may be 
 
 Fig. 48. Second stage in the operation for removal of a detached 
 semilunar cartilage from the knee. The internal lateral ligament has 
 been opened parallel to its fibres and its edges retracted. The synovial 
 membrane has been opened parallel with the incision in the Ugament, 
 thus exposing the edge of the internal condyle of the femur. The thumb 
 in the figure is represented as grasping a pair of forceps which is holding 
 up the edge of a displaced cartilage. The other forceps are attached to 
 the edges of the internal ligament and are being used as retractors. 
 
 divided transversely or vertically, though the vertical 
 incision is perhaps preferable, and the articular 
 surfaces of the joint then come into view. 
 
 By drawing the patella outwards the internal 
 cartilage and the infra-patellar pad (ligamenta 
 mucosa et alaria) are brought into view and may be 
 
156 INTERNAL DERANGEMENTS OF 
 
 thoroughly examined. The inter-condyloid notch 
 should in all cases be carefully explored, for into this 
 particular situation the cartilages are most fre- 
 quently displaced, and here also other loose bodies, 
 whether free or pedunculated, find a resting-place. 
 
 Fig. 49. The third stage of the author's operation for removal of 
 a detached semilunar cartilage. It shows the wound closed with a con- 
 tinuous silkworm gut suture and a wick of gauze inserted at the level 
 of the cartilage for drainage. The drain represented in the figure is too 
 long, and should be removed twenty-four hours after operation. The 
 extent and direction of the incision is well shown. 
 
 The displaced cartilage, whether torn or merely 
 loosened, is then seized with catch forceps, brought 
 into the space bounded by the edge of the patella, 
 tibia and femoral condyle, and snipped off with 
 scissors. 
 
 As much of the cartilage . as is loose should be 
 removed and no more. 
 
THE KNEE-JOINT 157 
 
 When more than the anterior portion of the 
 cartilage is loose and has to be removed, it may be 
 necessary to enlarge the incision backwards by 
 dividing the posterior fibres of the internal lateral 
 ligament transversely. This should be avoided when- 
 ever possible, as the joint is liable to be weakened 
 afterwards by the giving of the scar tissue even when 
 the union has been satisfactory at first. There are 
 surgeons who advocate a transverse division of the 
 ligament, but it is obvious that however good the 
 union may be it will be liable to yield when strain is 
 put upon it later. 
 
 The offending cartilage having been removed and 
 all bleeding stanched and blood removed from the 
 joint, a digital exploration of the other cartilage and 
 synovial folds should be made, on the same principle 
 as abdominal explorations are recommended as a 
 routine after laparotomy. 
 
 Thickened synovial fringes and folds, and even 
 pedunculated bodies, are not uncommonly met with 
 in long-standing cases, and, unless they are removed 
 at the time, will require subsequent treatment. 
 It is a good plan always to drain the joint for twenty- 
 four hours. Most surgeons do not drain, formerly 
 the writer did not, now he invariably does. He has 
 found from experience that unless the capsule is 
 drained, in nine cases out of ten it becomes rapidly 
 distended, usually with thin slightly viscous blood- 
 stained synovial secretion, sometimes with a thick 
 tenacious viscid material not unlike boiled sago. 
 Again, should any bleeding or oozing of blood take 
 place into the joint after the operation it will be 
 readily got rid of. Every surgeon must be aware 
 
158 INTERNAL DERANGEMENTS OF 
 
 Charts 1, 2, 3 and 4 were all taken from recent cases in 
 which one or other semilunar cartilage had been removed from 
 the knee by arthrotomy, and after a complete digital explora- 
 tion had been made. In Nos. 2 and 4 some fringes were clipped 
 away in addition. Note the difference in the temperatures of 
 
THE KNEE-JOINT 
 
 159 
 
 1 and 2, as compared with those of 3 and 4. In the former no 
 dramage was used, in the latter a gauze wick was inserted and 
 removed twenty-four hours later. In every other respect the cases 
 were treated aUke. These charts are typical of what the surgeon 
 should expect when operating with a strictly aseptic regime. 
 
160 INTERNAIi DERANGEMENTS OF 
 
 Charts 1, 2, 3 and 4 were all taken from recent cases in 
 which one or other semilunar cartilage had been removed from 
 the knee by arthrotomy, and after a complete digital explora- 
 tion had been made. In Nos. 2 and 4 some fringes were clipped 
 away in addition. Note the difference in the temperatures of 
 
THE KNEE-JOINT 
 
 161 
 
 1 and 2, as compared with those of 3 and 4. In the former no 
 drainage was used, in the latter a gauze wick was inserted and 
 removed twenty-four hours later. In every other respect the cases 
 were treated alike. These charts are typical of what the surgeon 
 should expect when operating with a strictly aseptic regime. 
 
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162 INTERNAL DERANGEMENTS OF 
 
 that the presence of blood in a synovial cavity 
 such as a knee is a serious complication when con- 
 sidered in the light of after-treatment. 
 
 Furthermore, pain is much less when drainage is 
 employed, and if we compare the temperature 
 charts taken of cases treated in all other respects 
 in exactly the same way with this single difference, 
 we may note that in those that are drained there 
 is about one degree less, showing that the absorption 
 from the joint and the tension are less. A thin 
 gauze drain is inserted and the membrane and 
 internal lateral ligament closed around it with 
 catgut sutures. The skin is sutured with silkworm 
 gut. An absorbent dressing is applied, and over 
 this a tight bandage, and the limb retained in the 
 slightly flexed position between sandbags, but with- 
 out a splint. 
 
 If the pain is severe, during the first night, aspirin 
 (grs. 10) may be given, or an injection of morphia 
 (gr. ^). Twenty-four hours later the drain should 
 be removed and an absorbent dressing re-applied. 
 On the eighth or ninth day the stitches should be 
 taken out and a collodion or celloidin-gauze dressing 
 substituted for the absorbent dressing. 
 
 The patella should now be moved from side to 
 side as it lies in the trochlea, but it is advisable to 
 defer other formal passive movements and massage 
 of the knee until a few days later. 
 
 In about fourteen days, if the wound is firmly 
 healed, the bandage may be discontinued at night, 
 re-applied in the morning and the patient allowed 
 to get out of bed and walk on crutches. All move- 
 ments may now be permitted, but the patient 
 
THE KNEE-JOINT 163 
 
 should not bear the weight of the body on the 
 affected leg for at least two weeks. In six weeks 
 the patient should be quite well and able for most 
 things. The results are usually excellent, and it is 
 quite exceptional to meet with a patient who is not 
 completely satisfied. A recent case was able to 
 play cricket in the University freshmen's match 
 eight weeks after the above operation had been per- 
 formed.^ 
 
 To ensure lasting success the patient must be 
 encouraged to persevere in carrying out all his 
 movements and not to rest satisfied until he is 
 capable of doing everything he was able to do 
 before the accident occurred. When walking is 
 first tried the knee should be held stiff while the 
 soles of the feet are placed flat on the ground. 
 
 Displaced external cartilage. There are several 
 cases of displaced external semilunar cartilage on 
 record, in most of which the detachments were 
 situated anteriorly ; in one or two exceptional cases 
 the posterior horn was ruptured. The tendency in 
 most of these was for the displacement to be inwards 
 towards or into the inter-condyloid space. Mr. 
 Annandale (British Medical Journal of February, 
 1887), relates a case in which the external cartilage 
 could be seen and felt displaced. Mr. Godlee {The 
 Transactions of the Path, Soc, vol. xxxi, p. 240) 
 showed a specimen taken from the dissecting-room, 
 in which the external cartilage had been torn from 
 its circumference, and lay in the inter-condyloid 
 notch. Mr. Langton, in The Pathological Society's 
 
 ^ The last two cases done by the author left hospital in twenty- 
 three days, walking well. 
 
 M 2 
 
164 INTERNAL DERANGEMENTS OF 
 
 Trans., 18S8, p. 282, mentions a case in St. Bartholo- 
 mew's Hospital of a loose body in the left knee. 
 The external semilunar cartilage had been torn from 
 its posterior attachment and was f m-ther detached 
 laterally for half or more of its length. Such cases, 
 for anatomical reasons, are extremely rare. The 
 writer has only met with three authenticated cases 
 in which the external cartilage had been detached ; 
 one occurred in the practice of a friend, another 
 in a patient from whom he had also removed both 
 internal cartilages. In these two cases the displace- 
 ment was into the inter-condyloid space and resulted 
 from a laceration near the junction of the anterior 
 and middle thirds which allowed the posterior 
 segment to alter its position. The third case 
 occurred in a youth who twisted his knee as the 
 result of a fall from a ladder. The accompanying 
 photograph shows the condition of his limb before 
 operation. He stated that he did not know what 
 happened to his knee, except that he ' felt something 
 snap ', and ' suffered agonies of pain '. His knee 
 immediately became swollen, and he was unable to 
 put the foot to the ground, nor was he able to keep 
 his knee fully extended. He was kept by his medical 
 attendant in bed for three weeks ; at the end of 
 this time, 'although most of the swelling had dis- 
 appeared, he was unable to put his foot to the ground 
 without pain, and he could not stretch* the limb to 
 its fullest extent. For over seven months he was 
 unable to walk any distance without considerable 
 pain. His occupation was that of a milkman, and 
 finding an increasing difficulty in doing his work, he 
 applied to the Radcliffe Infirmary for treatment. 
 
THE JKNEE-JOINT 165 
 
 On examination, the knee was found slightly bent 
 and could not by any means be fully extended. 
 There was marked atrophy of the muscles on the 
 proximal side of the joint, and though a thickening 
 
 Fig. 50. Case of long-standing displacement of left external semilunar 
 cartilage described in text. Note atrophy of muscles of thigh with com- 
 mencing hypertrophy of those of the calf ; also flexion of knee and fore- 
 shortening of limb. The discolouration shown was due to former blistering. 
 
166 INTERNAL DERANGEMENTS OF 
 
 of the synovial membrane was evident, there was 
 no distinct synovitis. He complained that, besides 
 the joint being painful, it was apt to swell if he 
 walked more than a few hundred yards. The photo- 
 graph shows plainly the posture of the limb and 
 atrophy of the muscles. After due preparation, the 
 knee was opened by a vertical incision corresponding 
 with a line over the centre of the base of the carti- 
 lage. The skin, the superficial fascia and the cap- 
 sule were divided in turn, the joint opened and the 
 cartilage exposed. It was found to have been torn 
 across at its posterior extremity, and as some of the 
 coronary ligaments had been detached, the cartilage 
 thus loosened could be caught between the bones in 
 certain movements of the limb. The movable part 
 of the cartilage was excised and the capsule sewn 
 up with catgut, a gauze drain inserted, and removed 
 twenty-four hours later ; the skin sutures, of silk- 
 worm-gut, were removed on the ninth day. The 
 patient left the hospital in three weeks. At the end 
 of five weeks he was completely cured as far as 
 movements were concerned, and able to do his 
 work as if nothing had happened. Regeneration 
 was taking place quite satisfactorily in the wasted 
 muscles of the thigh when he was last seen a month 
 ago (four months after operation). 
 
 From his experience of these cases the writer is 
 of opinion that when the diagnosis can be made, 
 especially if recurrences are frequent, the above 
 operation is the best method of treatment. 
 
 Since the above was written the author has met 
 with two more cases, making five in all. The last 
 one, a photograph of which is appended, occurred 
 
«-CALlFO 
 
 RH^fee 
 
 THE KNEE-JOINT 
 
 167 
 
 in a schoolboy aged sixteen who wrenched his knee 
 awkwardly at football. The diagnosis was made from 
 the history of the accident, the excessive tenderness 
 over the line of the cartilage, together with the 
 
 Fig. 51. Photograph showing characteristic flexion and swelUng in 
 left knee-joint, from a recent case of displaced external semilunar cartilage. 
 Note posture of Hmb as identical with that found in displacement of internal 
 cartilage. Diagnosis was subsequently verified by operation after he had 
 suffered a relapse. 
 
168 DERANGEMENTS OF KNEE-JOINT 
 
 characteristic posture of the limb ; the joint could not 
 be extended fully. Reduction was performed by 
 manipulation under complete anaesthesia, and the 
 joint was subsequently treated as an ordinary sprain. 
 Hypertrophied synovial fringes. In very chronic 
 long-standing cases of recurrent synovitis, it occa- 
 sionally happens that the synovial pad (the liga- 
 mentum mucosum) beneath the patellar ligament 
 becomes thickened and hypertrophied, the ligamenta 
 alaria on each of its borders become indurated, 
 thickened, and may even present papillated fringes. 
 As these structures increase in size, they are liable 
 to be caught and pinched or bruised between the 
 femoral condyles and the tibia. The bruising 
 further stimulates their increased growth so that in 
 time they form definite structures constantly liable 
 to injury. When nipped, they give rise to a sudden 
 pain and checking, rarely to locking, of the move- 
 ments of the knee. As a rule when the condition 
 exists by itself, it is suspected rather than diagnosed ; 
 an exact differential diagnosis being impossible. 
 When once begun, the tendency is for the symptoms 
 to increase rather than to diminish ; the disability, 
 therefore, is a progressive one. The condition is 
 best treated by opening the joint as for an explora- 
 tory arthrotomy and com_pletely clipping away the 
 whole of the infra-patellar swelling, being careful to 
 see that no thickened folds of synovial membrane 
 are left in the inter-condyloid space of the femur. 
 The fringes on rare occasions develop pedunculated 
 bodies which, although fixed or moored in the first 
 instance, become detached later and form one variety 
 of movable bodies in the joint. 
 
CHAPTER VII 
 
 GENERAL INJURIES TO MUSCLES AND 
 TENDONS 
 
 Muscles and tendons are liable to injury in many 
 ways, as the result of different forms of violence ; 
 thus they may be strained or sprained from over- 
 stretching, may become herniated or protrude 
 through openings in the fascia enveloping them, 
 displaced or dislocated from the grooves in which they 
 normally course, or even partially ruptured or torn 
 across. The tendons which surround a joint that 
 is sprained or dislocated almost invariably suffer, 
 though to a less extent than the ligaments. In 
 fractures they are often seriously damaged. 
 
 Muscle sprain. When the fibres of a muscle or 
 its aponeurosis or tendon are subjected to violent 
 overstretching or partial tearing, it is said to be 
 strained or sprained. This is a very common 
 occurrence in persons actively engaged in athletic 
 performances, less frequently in those who follow 
 laborious occupations. It is usually the result of 
 sudden violence when the muscle or group of muscles 
 are taken unawares, though in exceptional cases, 
 repeated muscular efforts may be accountable. 
 Many examples may be given, such as ' rider's 
 sprain ' affecting the adductors of the thigh, ' jumper's 
 sprain ' the hamstrings or muscles of the calf, 
 ' tennis elbow ' the pronator radii teres, ' driver's 
 
170 GENERAL INJURIES TO 
 
 or angler's elbow' the common origin of the supinator 
 extensors of the forearm, ' labourer's back ' with 
 which the sacro-lumbalis is concerned, and ' bowler's 
 side ' affecting the oblique muscles of the abdomen. 
 Each of these injuries, to which the popular name 
 has been given, is an example of muscle injury. 
 The symptoms are pain, tenderness on pressure, 
 with inability to carry out the particular movement 
 or movements concerned in the injury. As a rule, 
 recovery is rapid, though in some cases the individual 
 may not be able to resume his duties or to take part 
 in athletics for weeks or even months. 
 
 The treatment consists in discontinuing the move- 
 ments which give rise to spasm or pain when the 
 muscle or group of muscles are actively exercised 
 in performing their work. If the pain continues 
 and the recovery is delayed, a good plan is to support 
 the painful part with firm strapping, and to encour- 
 age the patient to use the muscles freely. Massage 
 and electric vibration are helpful, and may be used 
 when the strapping is removed for readjustment ; 
 or it may even be applied over the strapping. 
 
 The term ' strain ', as in the case of articular 
 injuries, is generally meant to indicate a disability 
 of less severity than sprain. 
 
 Herniae of muscles occur not infrequently among 
 young and powerfully built athletes, and are the 
 result of a sudden violent contraction of the muscle 
 when carrying out some supreme athletic effort. 
 The belly of the muscle, in shortening suddenly and 
 expanding proportionately in width, bursts its way 
 out and protrudes through its ensheathing fascia. 
 As a rule, the cleavage in the fascia is in the longi- 
 
MUSCLES AND TENDONS 
 
 171 
 
 tudinal direction, but it may be transverse. In 
 young cavalry soldiers, hernia of the adductor longus 
 muscle is not infrequently met with. The recruits, 
 often powerfully built men, trained to gymnastics or 
 marching, are suddenly ordered to mount and to 
 
 Fig. 52. Hernia of muscle in thigh, result of muscle sprain. 
 
 ride on barebacked horses, without stirrups. Un- 
 accustomed as many are to riding, it is not surprising 
 that, in their frantic efforts to escape falling off, 
 they rupture the sheaths of the adductor muscles in 
 gripping the horse. The tensor vaginae femoris, the 
 rectus femoris, the tibialis anticus, the rectus abdo- 
 
172 GENERAL INJURIES TO 
 
 minis, have all ajfforded examples. Hernise of 
 muscles are comparatively rare, and may be recog- 
 nized by the existence of a soft swelling in the course 
 of the muscle, which is soft and prominent when it 
 is relaxed, but becomes smaller and harder when it 
 is made to contract. Often there is no pain and 
 surprisingly little inconvenience ; the patient pre- 
 sents himself mainly to ascertain the cause of the 
 swelling, or for an explanation of a sensation which 
 has been met with in a certain number of cases, and 
 has been described ' as if water was trickling over 
 the part '. This latter symptom is probably due 
 to some interference in the course of a superficial 
 nerve. A feeling of insecurity is occasionally com- 
 plained of. 
 
 The diagnosis is easy, and in some cases where 
 the hernia is small, little or no treatment is required. 
 When the inconvenience is considerable, it may be 
 necessary to operate. If the case is recent, and the 
 split a longitudinal one, a curved incision through 
 the skin and fascia is made so that its convexity is 
 directed upwards over the course of the muscle, the 
 flap so marked out is turned downwards so as to 
 expose fully the rent in the fascia ; the muscle is 
 then put on the stretch to retract it. Any adhesions 
 that are present must be freed, and the edges of the 
 fascia brought together and sewn as accurately as 
 possible. There may be considerable ecchymosis 
 superficial to the fascia in the more recent cases. 
 When the rent is transverse, as occurs in the abdo- 
 minal rectus or in the long adductor of the thigh, 
 it may not be possible to bring the edges completely 
 together ; in such a state of affairs it is well to draw 
 
MUSCLES AND TENDONS 173 
 
 the edges together as near as possible and to fix them 
 as best we can with a stout catgut suture. 
 
 The after-treatment consists of resting the Hmb 
 until the external wound is healed, and then in using 
 gentle massage and encouraging slight active move- 
 ments. The results are almost invariably satis- 
 factory, even where the suturing of the fascia has 
 been incomplete. It has been suggested that the 
 hernia should be excised ; this is quite an unneces- 
 sary mutilation, and of very doubtful utility. 
 
 To prevent adhesion between the muscle fibres 
 and the line of suture, the Faradic current may be 
 employed with advantage, the movement occasioned 
 by the contraction of the muscle tending to stretch 
 or break down any adhesions that form. 
 
 Displacement or dislocation of tendons. Although 
 many cases are recorded, it may be said that, speak- 
 ing generally, displacements of tendons are rare. 
 The most familiar examples are the dislodgement of 
 the peroneus longus tendon from the groove behind 
 the external malleolus on to its external or anterior 
 surface, the tibialis posticus to the anterior surface 
 of the internal malleolus from its place behind it, 
 and the long head of the biceps flexor cubiti inwards 
 or outwards from the bicipital groove of the humerus. 
 The small tendons at the back of the neck are 
 occasionally displaced over the posterior tubercles 
 of the transverse processes of the vertebrae. In the 
 majority of cases, notably in those of the peronei 
 (longus et brevis) and the tibialis posticus, there is 
 in the course of the tendon a sudden and abrupt 
 deflexion around a bony prominence which takes 
 the place of a pulley. The bony prominence in each 
 
174 GENERAL INJURIES TO 
 
 instance is deeply grooved, so that the tendon lies 
 securely and is roofed in, so to speak, by a liga- 
 mentous expansion or confining sheath. The biceps 
 cubiti is displaced by the movements of the humerus 
 
 Fiu. 53. Dislocation of the peroneus longus tendon. Note formation 
 of false bursa between it and external malleolus. Taken from a schoolboy, 
 aged 15. Was restored subsequently by operation by author's method. 
 Vide text. 
 
 around it as it lies in a straight course in the bicipital 
 groove. The peronei may be found dislocated in 
 a patient who has sustained a violent twist or 
 wrench of the foot. 
 
 ' If, while the foot is either inverted or pointing 
 
MUSCLES AND TENDONS 175 
 
 straight forwards, the peroneus longus is made to 
 contract, it cannot sUp, for its tendon is tightly 
 drawn into the bottom of the groove at the back of 
 the external malleolus ; but when the foot is everted. 
 
 Fig. 54. Back view of displacement of both peroneal tendons (longus 
 et brevis) on right side. Note the bursarial enlargement over the external 
 malleolus. The photograph is unfortunately not a good one. 
 
 the tendon has a tendency to leave its groove, so 
 that its sheath becomes its pulley, and this, if the 
 strain is severe, may give way.' (Professor Howard 
 Marsh.) ^ 
 
 A schoolboy, aged sixteen, had been running in 
 1 Clinical Essays and Lectures, J. and A. Churchill, pp. 1-8. 
 
176 GENERAL INJURIES TO 
 
 his stocking soles after a football ; he accidentally 
 stepped on the ball, twisted his ankle and fell. When 
 examined a few minutes later, there was a large 
 extravasation of blood over the malleolus and on the 
 outer side of the ankle ; he complained of a sickening 
 pain and inability to move his foot, and vomited. 
 The tendon could be distinctly felt lying in front of 
 the malleolus, even through the effusion, and was 
 easily replaced by manipulation. The foot was then 
 placed at a right angle with the leg, inverted, and 
 fixed in this position by means of a moulded felt 
 splint. After forty-eight hours, massage and gentle 
 passive movements were begun (the tendon being 
 retained in position during the movements by the 
 fingers of the manipulator's other hand, while the 
 foot was kept inverted), and continued daily. At the 
 end of three weeks the splint was discarded, and as 
 all swelling had disappeared, the ankle was strapped 
 and the patient allowed to voluntarily exercise the 
 muscles of his foot with the movements of flexion 
 and extension. In four weeks he was able to walk, 
 though he complained of a feeling of weakness in the 
 ankle ; in six weeks he was quite well and able to 
 run. It is now over four years since the accident, 
 and there has been no recurrence. 
 
 If the foot, instead of having been everted, had 
 been inverted, the possibility is that he might have 
 displaced the tibialis posticus, for in this position 
 this muscle tends to leave the groove behind the 
 inner malleolus where it is merely retained in position 
 by the fibrous sheath upon which it pulls directly. 
 
 The author has seen a case in which both the 
 peronei tendons (longus et brevis) could be dislodged 
 
MUSCLES AND TENDONS 177 
 
 at will by the patient, a young lady, by simply 
 everting the foot in a sudden and jerky way. The 
 tendons jumped out of their grooves with a snap, 
 occasioning very little pain but producing complete 
 disablement. All discomfort and crippling disap- 
 peared as soon as the tendons were replaced, and this 
 could be readily and easily performed by gentle mani- 
 pulation. For years the patient treated the matter 
 with indifference, until finally the recurrences became 
 so frequent as to be annoying. The ordinary means 
 of retaining the tendons by strapping and wearing 
 a special appliance succeeded so long as they were 
 persevered with, but as soon as they were left off 
 recurrence took place. Accordingly, it was deemed 
 advisable to do away with the difficulty, and an 
 operation was performed. A curved incision was 
 made over the outer malleolus and side of ankle, the 
 flap turned upwards and the groove in the fibula 
 exposed. This groove was found to be shallow and 
 almost completely filled up by portions of the sheath ; 
 all this tissue was cleared out, the groove deepened, 
 the tendons replaced, and the remains of the sheath 
 stitched firmly and accurately over them with catgut. 
 The ankle was put into a moulded splint and, as 
 soon as the skin stitches had been removed at the 
 end of eight days, passive movements and massage 
 were begun and practised two or three times a day. 
 The result was in every way satisfactory. As recur- 
 rence seems, for anatomical reasons, so liable, imme- 
 diate operation appears to offer the best prospect 
 for a permanent cure ; contra-indications such as 
 enfeebled health and old age being alone considered. 
 Given a young, athletic and energetic person, an open 
 
 WHITELOCKE -j^ 
 
178 GENERAL INJURIES TO 
 
 operation gives far the best prospect of satisfactory 
 treatment ; the same means may be employed in 
 the case of the tibiaUs posticus. 
 
 The long tendon of the biceps has on many 
 occasions been displaced from its groove, either out- 
 wards or inwards, generally inwards, as a result of 
 violent or repeated movements of the upper arm, 
 such as are made use of in wringing clothes ; the 
 sheath which converts the groove into a tube is the 
 tendinous expansion of the pectoralis major, and 
 when this is torn across the tendon slips out. The 
 patient suffers pain, is unable to extend the forearm 
 until the tendon has been replaced by abducting 
 the arm and manipulating it. The displacement 
 may often be produced voluntarily, and in such cases 
 needs no special treatment. Reduction may be 
 brought about by manipulation ; a good plan is to 
 direct the patient tc place his hand on the shoulder 
 of another person, and while it is thus abducted, 
 advise him to carry out the movements of rotation 
 first in one direction and then the other. 
 
 The small tendons at the back of the neck are 
 not infrequently displaced, resulting in temporary 
 locking with pain, which is sometimes very acute, 
 and centred at the exact spot. Such accidents occur 
 from some sudden and awkward movement of the 
 head, as in turning hurriedly to one side or the other. 
 
 An example would perhaps better explain matters. 
 A young man, leaning out of an upstairs window 
 and talking to his companion in the garden below, 
 was suddenly startled by the banging of a door 
 behind him. Turning his face to the right sharply, 
 he heard a ' click ', felt an agonizing pain in the 
 
MUSCLES AND TENDONS 179 
 
 right side of his neck, found his chin approximated 
 to his right shoulder and fixed in that position. 
 Every attempt at straightening the neck or moving 
 his head to its proper position was impossible, by 
 reason of the pain, which was most intense. It was 
 obvious that a small tendon had been displaced, and 
 presumably a portion of the splenius capitus or other 
 muscle had become caught and hitched over the 
 posterior tubercle of one of the transverse processes 
 of an upper cervical vertebra. Holding his head 
 between his hands, and with an expression of mingled 
 fear and anxiety, he presented himself, saying : ' For 
 God's sake, doctor, be quick, for I've either broken 
 my neck or slipped it out of joint ! ' After reassuring 
 him with no little difficulty on this score, nitrous 
 oxide gas was administered, and by means of gentle 
 rotation, combined with to-and-fro movements of 
 the neck, the trouble was after some difficulty over- 
 come. As soon as the patient recovered from the 
 anaesthetic he volunteered the statement that he was 
 absolutely free from any pain. 
 
 A few days ago an undergraduate arrived with 
 his head turned to one side so that the vertex was 
 approximated to his left shoulder ; he complained of 
 acute pain whenever he attempted to straighten his 
 neck, or indeed to carry out any movement other 
 than that of bending his head towards the left 
 shoulder. He stated that while swimming in a bath, 
 engaged in a game of water-polo, he turned his head 
 suddenly to the left in endeavouring to see the ball ; 
 felt something snap, and believed that he had dis- 
 located his neck. On making an examination it 
 was found that he had pain on pressure over the 
 
 N 2 
 
180 GENERAL INJURIES TO 
 
 fourth and fifth cervical vertebrae posteriorly, which 
 was intensified with any attempt at movement. By 
 gently massaging and stroking the muscles of the 
 back of the neck on both sides of the spine, the local 
 pain was in a short time considerably diminished ; 
 then standing behind the patient, who was seated 
 on a low chair, and laying hold of the painful place 
 with the left hand and approximating the left side 
 of his face to his shoulder so as to relax the muscles 
 on that side, reduction was brought about by a gentle 
 rotation of the head from left to right. While the 
 movements of rotation were being executed, the dis- 
 located tendons were manipulated with the fingers 
 of the left hand. Pain was immediately relieved and 
 the patient walked out apparently well. On the 
 day after, he was again seen, and complained of 
 nothing more than a slight tenderness over the left 
 side of the neck ; no fixing apparatus was thought 
 necessary, and the case did well. Other similar cases 
 are on record : one in which a jockey, in riding 
 home an easy winner, was incautious enough to 
 suddenly turn his head over his shoulder that he 
 might see the other riders. His head became fixed 
 in this position and he rode home past the winning 
 post still looking backward, much to the astonish- 
 ment of the onlookers ! On dismounting, many 
 attempts were made by friends and admirers to 
 rectify matters, but their efforts were all to no pur- 
 pose. A surgeon coming on the scene, with the aid 
 of some chloroform, enabled him to fulfil his engage- 
 ment to ride another race ; which he did, history 
 relates, again with success. 
 
 On a few occasions, hospital patients of the labour- 
 
MUSCLES AND TENDONS 181 
 
 ing class have applied for assistance with the history 
 of having ' ricked ' the muscles of the back, either 
 in lifting or in slipping awkwardly while carrying 
 loads either up or down a ladder. These have been 
 usually regarded as displace^ients of portions of the 
 sacro-lumbalis muscle, since they are almost invari- 
 ably relieved by the administration of an anaesthetic 
 aided by deep rotatory manipulation and kneading. 
 Indeed, these simple expedients are usually so 
 eminently successful that they recall to one's mind 
 in a forcible way the fabulous results of the old time 
 bone-setters who, by their various manipulations, 
 wrought miracles, but with this difference, that in 
 these particular cases there is genuinely a ' something 
 out of place '. 
 
 The after-treatment is simple. There is seldom 
 any sign of haemorrhage or ecchymosis, the pain 
 being immediately relieved by the manipulations ; 
 only a certain degree of tenderness remains which 
 may last for three or four days. A bandage or some 
 adhesive strapping may be applied over the seat of 
 mischief, more as a placebo than a necessity. 
 
 Various other tendons in the body have been at 
 times displaced, but the occurrence is so rare that 
 little notice need be taken regarding them here. 
 The principles of treatment are the same for all. 
 
 Rupture of muscle or tendon. A muscle or tendon 
 may be ruptured in almost any part of its course, 
 either in its continuity or near to its points of attach- 
 ment. In the greatest number of cases it occurs 
 where the muscle fibres join with the tendinous. 
 Each individual muscle would seem to have its weak 
 spot, and rupture takes place with remarkable regu- 
 
182 GENERAL INJURIES TO 
 
 larity at certain definite situations. Degenerated 
 and enfeebled muscles are no more prone to rupture 
 than are the muscles of healthy and vigorous persons. 
 
 Tearing of muscle may result from outside injuries, 
 such as blows and crushes, but is more generally 
 occasioned by sudden, indirect, and involuntary 
 forms of violence. When rupture takes place in the 
 belly of a muscle, the fibres contract and retract, 
 the amount of separation depending upon the length 
 of the muscle between its proximal and distal attach- 
 ments, as well as its limitations by a lateral or other 
 attachment, to a bone or neighbouring aponeurosis. 
 
 The long muscles in the extremities furnish the 
 best examples of separation after tearing. When 
 a muscle is torn, the space between its retracted 
 ends becomes rapidly filled with blood, which is 
 poured out from the lacerated veins for the most 
 part, though occasionally the bleeding is arterial. 
 The haemorrhage in certain cases is large in amount, 
 and gives rise to much swelling. In all cases, how- 
 ever slight, there is some bleeding ; this is an impor- 
 tant fact in the matter of treatment. The blood 
 clots and forms a temporary bridge or platform 
 between the divided ends ; this is ultimately re- 
 placed by fibrous tissue which in the end forms 
 a link of union between them. Not infrequently, 
 when a tear takes place through the belly of a long 
 muscle, the fibres of the proximal end are curled 
 upon themselves within the sheath of the muscle, 
 and form adhesions in faulty positions ; or may even 
 become tucked up behind and give rise to increased 
 shortening and a proportionately longer interval. 
 The distal end of a torn muscle or tendon invariably 
 
MUSCLES AND TENDONS 183 
 
 undergoes degeneration when its nerve of supply 
 happens to be cut off. More frequently, muscles are 
 only partially torn across, and we meet with every 
 degree, from laceration of a few peripheral bundles 
 of fibres to complete severance of the whole muscle. 
 Speaking generally, partial lacerations are found in 
 the short and flat muscles of the body, while the 
 long muscles of the extremities afford examples of 
 the complete. Instances of complete rupture are 
 found amongst those which have been brought about 
 by sudden and unexpected contractions. Athletic 
 exercises produce many, so much so that a con- 
 siderable number of these injuries have derived 
 popular names from the particular form of sport or 
 exercise in which they occur ; thus we have ' bowler's 
 side', 'rider's sprain', 'lawn-tennis leg', 'cricketer's 
 shoulder', and 'sprinter's thigh'. The clinical symp- 
 toms are characteristic and alike in both groups. 
 There is usually a history of sudden pain localized 
 in some definite spot, with the sensation as if struck 
 by a whip or a stone, or as if something was torn. 
 A distinct snap may be heard and the limb becomes 
 powerless. At the seat of rupture there is tenderness 
 and swelling. When the swelling is insignificant, or 
 the separation great, a distinct gap may be felt in 
 the muscle, which increases in width whenever it is 
 made to contract. The treatment is therefore indi- 
 cated according to the importance of the particular 
 muscle involved, and to the degree to which it is 
 incapacitated. An important muscle, such as the 
 quadriceps extensor of the thigh, may require an 
 immediate operation, whereas a small one like the 
 plantaris may be treated equally well by posture 
 
184 GENERAL INJURIES TO 
 
 and strapping. Approximation of the fibres is of 
 the first importance, and whilst in the one case this 
 may be best carried out by an open operation with 
 careful suturing of the fibres and their sheaths with 
 catgut, in the other, bandages, strappings, and special 
 contrivances will be all that is required. Primary 
 and immediate suture, if done within a few days, 
 gives far better results than secondary suture at 
 a later period. Partial ruptures result from the 
 same kind of injury as complete, and give rise to the 
 same inconveniences, though to a lesser degree. 
 There is pain and tenderness, and even a slight 
 depression or gap may be felt. 
 
 The treatment consists of strapping, rubbing, and 
 active movements. Absolute rest is, however, not 
 to be recommended as a rule. 
 
 Athletic exercises are responsible for lacerations 
 in almost all the muscles and tendons of the body 
 at some time or other, and more especially is this 
 the case with those who take part in violent athletic 
 exercises without first training these structures 
 gradually. The system of training here referred to, 
 is that of gradually increasing exercise, and has no 
 necessary regard to dietary or other considerations. 
 At the public schools and universities, where 
 athleticism is a recognized accomplishment, and 
 where youth and early manhood, and to a limited 
 extent early middle life, enter into real competition, 
 there is no kind of injury so commonly met with as 
 that of sprained, overstretched, dislocated or lacerated 
 muscles or tendons. During the last twenty years 
 the writer has had an extensive experience at one 
 of the old universities, and has come to the conclusion 
 
MUSCLES AND TENDONS 185 
 
 that, for some reason or other as yet unexplained, 
 these accidents seem rather to be on the increase 
 than otherwise. Few muscles in the extremities 
 escape, nor are the muscles of the trunk exempt. 
 Certain circumstances would seem to influence this 
 tendency to rupture, and among them may be 
 enumerated 
 
 1. The season of the year. 
 
 2. The temperature of the air. 
 
 3. Want of training or fitness. 
 
 4. Age and physique of the individual. 
 
 5. The kind of game or exercise. 
 
 It has often been observed and remarked upon 
 that at the universities and pubUc schools there are 
 more athletic accidents during the autumn or October 
 term than at any other time or season. The reason 
 probably is that during the long vacation athletes 
 have been employed in carrying out forms of exercise 
 different from those of set athletics. When they 
 return to school or college, without having had 
 sufl[icient or gradual training, they plunge at once 
 into strenuous games of football, running, and 
 rowing. It is therefore not surprising that their 
 tendons are ruptured and their ligaments torn. 
 
 The temperature of the air undoubtedly influences 
 the muscles. The teaching of modern physiology 
 would have us know that while cold retards muscular 
 contraction, warmth accelerates it ; cold renders 
 muscle tissue more inelastic, and inelastic muscles 
 are more prone to laceration. The winter months, 
 the cold seasons, assisted often by a want of proper 
 clothing, bring many to seek the assistance of the 
 surgeon. 
 
186 INJURIES TO MUSCLES AND TENDONS 
 
 Want of training is a self-evident cause. Tendons 
 must be made accustomed to the pull of their 
 attached muscles if they are to meet with their 
 attacks successfully. Unless the muscles are 
 gradually trained to the requirements of the indi- 
 vidual, they will, indeed are forced to yield under 
 some unexpected and supreme effort. And this leads 
 to the following statement, that even in the case of 
 a thoroughly trained athlete, whose muscles are 
 properly tuned, so to speak, it would appear that 
 his muscle is torn not entirely by its own contraction, 
 but rather by the contraction of the antagonistic 
 muscles taking place before its own act of contraction 
 was completed. 
 
 Age influences in a measure. The younger the 
 athlete, the more supple are his tendons, and perhaps 
 within certain limits the less powerful is the pulling 
 force of the muscular fibres proportionately to the 
 tendinous. Men of good physique are more liable 
 than weaklings. 
 
 The kind of game affects the proportion of injuries ; 
 thus football and rowing are more productive than 
 sprinting or long distance running. Hugby football 
 accounts for more accidents than Association, though 
 generally they are of a less severe type. 
 
CHAPTER VIII 
 
 INDIVIDUAL INJURIES TO MUSCLES AND 
 TENDONS 
 
 In the preceding chapter certain details were given 
 as to the management of the lesser injuries to muscles 
 and tendons, such as overstretching, hernia, and 
 displacement, where, on the whole, the symptoms 
 are never severe and the disablement not particu- 
 larly serious. 
 
 In this chapter it is proposed to deal more in 
 detail with the rupture of muscles and tendons, 
 since they often lead not only to considerable 
 crippling at the time, but also, if mismanaged or 
 improperly treated, to permanent loss of power. 
 
 As has been already pointed out, almost any long 
 muscle or its tendon may be ruptured, and as it 
 would be tedious to treat of each individually, only 
 certain of the most important will be considered, 
 and no reference will be made to laceration produced 
 by external injury, or tetanus, or during parturition ; 
 allusion will therefore only be made to the rupture 
 of muscles by their own forcible contraction during 
 ordinary or violent athletic 'movements. The princi- 
 ples of treatment are the same for all, whatever the 
 cause. 
 
 The muscles of the trunk are sometimes ruptured 
 when direct violence is applied to them, especially 
 when contracted ; they may also be ruptured by 
 their own forcible contractions. 
 
188 INDIVIDUAL INJURIES TO 
 
 The abdominal rectus has been torn in a patient 
 enfeebled by enteric fever simply turning in bed or 
 attempting to rise from the recumbent position. 
 Cavalry soldiers have been known to tear the muscle 
 in mounting on to horseback, and rowing men from 
 missing a stroke in pulling. 
 
 The chief symptoms are a sudden stablike pain 
 below the umbilicus (for rupture always is below 
 that point) and inability to straighten the body ; 
 a swelling is present, transverse to the line of the 
 body and to one side of the middle line, which is 
 often of extensive proportions. Usually there is no 
 sulcus to be felt, nor ecchymosis to be seen at first. 
 The swelling has been mistaken for umbilical hernia 
 and cold abscess. 
 
 Treatment consists, in a mild case or one of partial 
 tearing, in flexing the body so that the chest ap- 
 proaches the pelvis, and maintaining this position 
 in bed for one or two days. Plaster strapping is 
 very useful (vide Fig. 55), and may be applied from 
 the chest to pelvis anteriorly in strips or in one 
 broad piece of strapping. When the rupture is com- 
 plete and the haemorrhage extensive, an open opera- 
 tion with suture of the muscle and its sheath is 
 strongly advocated ; for much time is saved, and 
 the probability of an abdominal hernia prevented. 
 
 The oblique muscles of the abdomen are often 
 partially torn by awkward twists or wrenches of the 
 body. The pain is referred usually to the attach- 
 ments in the neighbourhood of the twelfth rib, but 
 occasionally also along the crest of the ilium. Tender- 
 ness on pressure will localize the exact seat of mischief. 
 Swelling at first may be inconsiderable, while later 
 
MUSCLES AND TENDONS 189 
 
 the signs of bruising (play of colours) may be well 
 marked. The affection known as ' bowler's side ' 
 is the result of the tearing of sotne fibres of one or 
 both oblique muscles, and results from fast bowling 
 on a wet and slippery wicket. 
 
 The most suitable treatment is to strap as for 
 
 Fig. 55. Rupture of right rectus muscle of the abdomen with strapping 
 applied of a single piece of wash-leather plaster. The strapping should 
 reach from the upper thigh to the margins of the ribs, and be fixed above 
 by a cross piece, and made to extend across the middle line of body. The 
 transverse slip of plaster should be laid on firmly and not loosely as here 
 showTi. 
 
 a broken rib, from the spine around the injured side 
 across the middle line in front to the other side, com- 
 mencing about four inches above the last rib, and 
 extending well below the iliac crest {vide Fig. 56 b), 
 then allowing the patient to go about as usual after- 
 
190 INDIVIDUAL INJURIES TO 
 
 wards. Cure will usually result in from twelve to 
 fourteen days. 
 
 The ilio-psoas muscle is rarely completely torn, 
 though partial tearing is not an uncommon occur-^ 
 rence in beginners at rowing. It results from an 
 awkward swing of the body in the leg drive from 
 the stretcher, and is more often produced with a fixed 
 than sliding seat. There is pain in straightening the 
 body, felt in the iliac fossa and upper thigh, and there 
 may be considerable ecchymosis immediately below 
 Poupart's ligament. The treatment consists of rest 
 for a few days from the particular movements in- 
 volved. No local application seems of much service, 
 and strapping helps but little. The ilio-psoas tendon 
 has been ruptured in the thigh in a boy who attempted 
 to lift a heavy basket ; the injury was followed by 
 extensive swelling. 
 
 The sacro-lumbalis may be partially dislocated or 
 torn. Replacement of displaced fibres under an 
 anaesthetic, and subsequent plaster strapping is 
 usually sufficient. While there is always tenderness 
 over the seat of the rupture, the swelling seldom 
 shows externally, though doubtless effusion takes 
 place between the deep muscular planes. 
 
 In the upper extremity, the pectorals, deltoid, 
 biceps (both long and short heads), are the most 
 commonly torn; very rarely fibres of the triceps and 
 muscles of the forearm. These result generally from 
 indirect violence. 
 
 The pectorals have been torn in violent efforts 
 to prevent a fall by catching at a suspended rope. 
 The symptoms are pain on movement, tender- 
 ness on pressure, severe ecchymosis over the side 
 
MUSCLES AND TENDONS 
 
 191 
 
 of the chest, and complete inability to use the 
 shoulder. 
 
 Treatment by strapping and posture. 
 
 * Cricket shoulder ' is a strain produced in throwing 
 
 B 
 
 Fig. 56. a. Strapping applied for sprains of the intercostal muscles and 
 side. The plaster should encircle at least two -thirds of the circumference 
 of the body and be laid on from above downwards during expiration. 
 
 B is for sprain or rupture of the obhque muscles of the abdomen — 
 * bowler's side '. The plaster should extend from the lower thorax to 
 below the crest of the iUum. 
 
 a ball, and is usually caused by the rupture of some 
 fibres of the deltoid near to its insertion, or to the 
 overstretching or partial laceration of the sheath of 
 the pectoralis major, where it encloses the long head 
 
192 INDIVIDUAL INJURIES TO 
 
 of the biceps in the bicipital groove. It has been 
 reported that even the head of the biceps has been 
 displaced in the effort of throwing a cricket ball. 
 Since the deltoid is very prone to atrophy and stiff- 
 ness whenever it is injured, it should never be fixed 
 in a position of rest ; on the contrary, it is wise to 
 strap the shoulder- joint with adhesive plaster and 
 allow the patient to begin the ordinary movements 
 early in the treatment. The same may be said in 
 respect to the treatment of the long head of the 
 biceps, for, if left in repose, adhesions are liable to be 
 formed and extend even into the. joint itself, leading 
 to permanent stiffness. All that is really necessary 
 is to strap, rub, and encourage early movements. 
 When such an injury has been neglected, and the 
 deltoid has borne the brunt of the injury, it becomes 
 imperative to develop the powers of the muscle by 
 special exercises, so that the muscle fibres are made 
 to contract. Graduated weights and pulleys are 
 sometimes needful in aggravated cases. 
 
 When the biceps tendon is chiefly affected, the 
 adhesions may be loosened and broken down under 
 an anaesthetic preliminary to other treatment. 
 
 The biceps flexor cubiti is often ruptured by its 
 own forcible contraction and may suffer in one or 
 other head or in the belly of the muscle after the 
 union of its two parts.. The most common injury, 
 and perhaps the most troublesome to deal with, is 
 separation of the long head from its scapular origin. 
 No method of treatment by posture seems satisfac- 
 tory, for the end of the tendon is pulled away from 
 its attachment in the glenoid cavity. Theoretically, 
 an operation would seem the most suitable, but it 
 
MUSCLES AND TENDONS 193 
 
 involves opening the joint, so that it is doubtful 
 whether it is worth the while or is really practicable. 
 The method generally adopted is that of fully flexing 
 both the shoulder- and elbow- joints, strapping the 
 arm across the chest, and maintaining it in this 
 position for at least a month. The writer has met 
 with only two such cases in his whole experience. 
 The first he treated after the manner just described, 
 and obtained but a moderate result. The second he 
 met with five months after the injury, and although 
 in this case there had been no attempt to retain the 
 arm in the flexed position for longer than a week, the 
 result was, to say the least, as good if not better than 
 in the former. This has led him to the conclusion 
 that such a case would be better treated as other 
 cases of rupture are, by strapping and early move- 
 ments, avoiding for a time anything that will unduly 
 impinge on the injured tendon itself. The diagnosis 
 is very simple, and the treatment of rupture through 
 the belly of the muscle is by ordinary surgical 
 principles. 
 
 Rupture of some of the tendons of the forearm 
 has been met with, and others have been described, 
 but they are exceedingly rare and may be dealt with 
 by the ordinary means. 
 
 In the lower extremity many of the muscles and 
 tendons are liable to rupture, thus one or other 
 muscle or tendon in the extensor and adductor 
 groups of the thigh, as well as the hamstrings, 
 suffer as the result of violent athletic exercises, 
 while rupture of the calf muscles is no uncommon 
 occurrence. 
 
 The rectus femoris may tear in any part of its 
 
 WHTTELOCKE q 
 
194 INDIVIDUAL INJURIES TO 
 
 muscular course, or its direct head may pull o& the 
 epiphysis for the anterior inferior spinous process of 
 the ilium in persons under the age of eighteen. The 
 accompanying photograph shows a typical example 
 of rupture through the body of the muscle. It 
 happened to a gentleman in endeavouring to keep 
 his balance while skating. This form of injury, as it 
 sometimes occurs in a sudden effort to run while 
 fielding at cricket, has been called ' cricket thigh '. 
 Two cases of separation of the epiphysis for the 
 anterior inferior spine of the ilium were reported by 
 the writer in the Lancet for 1893.^ They occurred in 
 undergraduates who injured themselves while start- 
 ing in a sprinting race when the body was suddenly 
 made to assume the erect position after being in 
 a stooping one. The details as to the precise 
 mechanism of the injury and its subsequent treat- 
 ment are there fully gone into. It is sufficient to 
 state that they were at that time treated as a fracture 
 would be, with a plaster of Paris spica-bandage. 
 
 The symptoms of rupture in the rectus femoris are 
 surprisingly slight. There is little pain, often the 
 feeling of snapping or tearing is experienced, followed 
 by a weakness in the limb. Swelling may be imme- 
 diate and extensive and even mask the presence of 
 the usual sulcus when viewed for the first time ; 
 palpation will, however, very readily disclose its 
 presence. 
 
 Treatment depends upon circumstances. The 
 direct head, with its detached epiphysis, may be 
 
 1 ' Separation of the Epiphysis for the anterior inferior spinous 
 process of the ihum through enforced muscular action.' By 
 R. H. AngUn Whitelocke, Lancet, 1893. 
 
MUSCLES AND TENDONS 195 
 
 treated by temporary fixation !by strapping and 
 allowing the patient to walk about, or by a plaster 
 of Paris bandage and crutches. The former plan will 
 
 Fig. 57. Rupture of rectus femoris muscle, done while skating. Patient 
 subsequently displaced the internal semilunar cartilage of his knee, which 
 was removed by the author. The scar on the inner surface of the joint 
 represents the line of incision. 
 
 probably, judging by analogy, yield a more satis- 
 factory result. Where there is complete rupture 
 through the belly of the muscle, especially where 
 there is a large haematoma and no serious contra- 
 
 o 2 , 
 
196 INDIVIDUAL INJURIES TO 
 
 indication as to general health, the open operation 
 is the most suitable. When the rupture is only 
 partial, strapping the thigh with broad strips of 
 Seabury and Johnson's perforated rubber plaster so 
 as almost to encircle the limb and draw the muscles 
 
 Fig. 58. Photograph of thighs of patient to show on the right side 
 author's method of strapping for rupture of fibres of the hamstring muscles. 
 The plaster is not allowed to meet, or to completely encircle the Hmb. 
 A space is left to allow of muscular expansion during exercise. For 
 rupture of the adductors or extensors of the thigh the separated ends 
 are placed externally. 
 
 together, is quite efficacious. The plaster (vide 
 Fig. 58) should be applied in strips at least three 
 inches wide. It should never be allowed to encircle 
 the thigh completely. A good plan is to leave a gap 
 of about an inch between its ends. This gap allows 
 
MUSCLES AND TENDONS 197 
 
 enough play in the muscles of the thigh during 
 walking and other exercises, and unless it is left, 
 when the muscles enlarge by contraction, they will 
 either burst asunder the application, or tear their 
 own fibres at the point of greatest constriction. The 
 plaster, properly applied, gives ample support, and 
 enables the individual to walk about at once, and in 
 the milder cases he may even resume his athletic 
 exercises in the space of a few days. Another result 
 of the injury is met by this method of strapping. 
 The skin and fasciae are supported by the firm, more 
 or less resilient, plaster, so that the extravasated 
 material is compressed. As the patient walks, the 
 muscles of the thigh, owing to their contraction, 
 become alternately larger and smaller, so that a to- 
 and-fro movement is exerted on the materials that 
 are extravasated between them and the overlying 
 skin ; by this churning process the extravasation 
 becomes dispersed up and down the thigh under the 
 strapping, and is driven by the elastic compression 
 in the direction of the venous flow, and hurried 
 onward into the general circulation. The effect 
 produced on the local circulation is not unlike that 
 of friction massage. 
 
 The advantages of strapping when applied to 
 ruptured muscles may be summarized as follows. 
 When it is evenly and smoothly applied, further 
 extravasation becomes impossible ; the muscles are 
 supported so that further tearing is prevented ; it 
 becomes safe to allow the individual to walk or to 
 otherwise exercise his muscles, and the exercise will 
 not only prevent weakness and muscle atrophy, but 
 it actually disperses and drives onwards all local 
 
198 INDIVIDUAL INJURIES TO 
 
 extravasated material into the general blood-stream. 
 Healthy local nutrition is ensured with much cer- 
 tainty, as the general health of the patient will be 
 bettered if he is allowed to go about rather than 
 live in the house during convalescence. This is the 
 whole rationale for the use of strapping in the treat- 
 ment of ruptured muscles. The fibres that are torn 
 seldom unite completely, and this seems a matter 
 of little consequence, for other fibres develop to take 
 their place, or neighbouring muscles enlarge to make 
 up for any deficiency. The limb should be carefully 
 shaved, washed over with a spirituous lotion and 
 sponged dry before the rubber plaster is applied. 
 Seabury's Rubber Plaster is sufficiently adhesive, 
 and as it contains rubber does not readily slip. The 
 perforations allow of a measure of evaporation, yet 
 even this will not prevent a modicum, of eczematous 
 irritation occurring in the skins of certain individuals. 
 The irritation when it does occur acts therapeutically 
 as a somewhat mild counter-irritant, and perhaps in 
 the end does good and compensates the individual 
 for his discomfort. As soon as the plaster becomes 
 loose by reason of the absorption of the subjacent 
 extravasation, it must be removed and re-applied ; 
 this may be necessary on the second or third day 
 when the extravasation has been copious in the first 
 instance. 
 
 Rupture of the quadriceps extensor tendon is 
 a troublesome injury, and results from sudden effort 
 to regain the balance. Whether the patella fractures 
 or this tendon or the ligamentum patellae tears usually 
 depends upon the amount of flexion in the limb at 
 the time the strain takes place. The diagnosis is 
 
MUSCLES AND TENDONS 199 
 
 easy, the gap in the tendon with loss of power iit the 
 limb are quite sufficient to distinguish the condition. 
 
 The treatment is of the greatest importance. In 
 slight cases, where there is only partial rupture some 
 distance from the knee and without much extravasa- 
 tion, the method of strapping mentioned above will 
 suffice, providing also that the limb is kept in the 
 extended position for about ten days. The leverage 
 at the knee is so great that it would be unwise to 
 allow flexion before some definite healing had had 
 time to take place. When the rupture takes place 
 near the patella the matter is most serious, and it 
 should be treated just as if the patella itself had been 
 fractured. The joint is sure to be opened into and 
 to be full of blood. When there are no definite 
 contra-indications such as organic disease or the 
 patient's refusal to allow operation, the joint should 
 be immediately opened, the clots turned out, and 
 the fibres of the tendon sutured as accurately as 
 possible with catgut. 
 
 The writer has performed this operation on several 
 occasions, always with success, and is fully con- 
 vinced that if the surgeon has perfect confidence in 
 his operative technique, he will obtain better results 
 by the open method than by any other. The patient 
 will be able to walk in four weeks and to do practi- 
 cally anything in six weeks, providing always that 
 his splints are left off not later than a fortnight, or 
 soon after complete healing has taken place in the skin 
 wound, and that early movements are practised. The 
 details of the operation will be described more fully 
 when dealing with rupture of the patella ligament. 
 
 The hamstrings are seldom torn across completely ; 
 
200 INDIVIDUAL INJURIES TO 
 
 the* writer has never met with a case, though partial 
 tears are very common in broad- jumpers, sprinters, 
 and football players. The two most common sites 
 are close to the common origin from the tuberosity 
 of the ischium and about the centre of the back of 
 the thigh. The biceps, semi-tendinosus, and semi- 
 membranosus, may all suffer. The tearing results 
 from an awkward landing in the broad- jump by the 
 individual endeavouring to prevent falling backwards 
 after the jump. Sprinters unaccustomed to run in 
 shoes with spikes and without heels frequently tear 
 portions of the hamstring muscles before they get 
 into proper training. A rarer injury is one found in 
 the neighbourhood of the insertions of the semi- 
 tendinosus and gracilis to the inner surface of the 
 tibia below the knee, caused by an overstretching 
 in certain lateral movements of the leg while 'side- 
 kicking ' at Association football. It gives rise to 
 pain, swelling and impaired movements. A depres- 
 sion may be felt in the hamstring tendons close to the 
 ischial tuberosity, but in the majority of cases the 
 diagnosis is made from the history of ' something 
 going ' during running or jumping, and although at 
 first there are few signs of extravasation, the usual 
 play of colours of an old bruise will develop later. 
 The treatment consists in raising the heel of the boot, 
 strapping as for other muscle-tears on the thigh, and 
 allowing the patient to walk about from the very 
 first. As a rule the cure is effected in about fifteen 
 days. Recurrences, however, are not uncommon. 
 
 In the adductor group, the adductor longus et 
 brevis, as well as the pectineus, are torn, from muscu- 
 lar efforts pure and simple. 
 
MUSCLES AND TENDONS 201 
 
 The adductor longus is so frequently injured in 
 those engaged in horse-riding — as cavalry soldiers 
 and huntsmen — that the name of ' rider's sprain ' is 
 now almost universally adopted in surgical literature 
 to denote this particular affection. The muscle may 
 be torn close to the pelvic attachment or at its lower 
 end ; when in the former situation, which is the 
 more usual, the nerve of supply is often damaged 
 and atrophy follows. There is always extensive 
 bleeding, and the swelling passes up to, or even 
 above, Poupart's ligament, and down into the peri- 
 neum and thigh. The pain is sometimes slight and 
 out of all proportion to the severity of the injury, 
 but not uncommonly there is a severe stabbing pain 
 referred to the region of the anus. The loss of 
 adductor power is considerable, and the tenderness 
 on pressure over the whole region is marked. The 
 diagnosis is simple ; the history of something ' snap- 
 ping ' while riding a swerving horse, or in mounting 
 a restive animal, inability or difficulty in performing 
 adduction, followed by severe extravasation and the 
 presence of a gap in the course of the muscle, make 
 it certain. 
 
 The treatment in recent cases is directed to pre- 
 venting and removing the extravasation. Much time 
 will be lost if the old regime of using cold lotions is 
 adopted. Either elastic pressure by means of cotton- 
 wool and a bandage, or firm rubber-strapping serves 
 the purpose better. If a definite haematoma forms, and 
 there is no reason against it, an incision should be 
 made, the clots removed, and the muscle itself either 
 sutured or excised. The loss of the muscle is sur- 
 prisingly little felt. Cases are on record where it 
 
202 INDIVIDUAL INJURIES TO 
 
 has been removed late in the ease because the 
 proximal end formed a painful swelling, troublesome 
 to the rider, and in a few which were followed by 
 ossification. The other adductor muscles develop 
 and take on its functions. In mild or incomplete 
 cases the part should be strapped with plaster, and 
 the individual allowed to walk about, or even ride 
 a quiet steady hack after a few days. Some of the 
 writer's most successful cases have been treated in 
 this way. When the adductor brevis or pectineus 
 are torn they must be treated on similar lines. 
 
 The adductor magnus tendon, at its insertion into 
 the adductor tubercle, is sometimes strained in 
 injuries involving the inner side of the knee. Tender- 
 ness is occasionally experienced extending along the 
 muscle high up into the thigh when the internal 
 lateral ligament of the knee has been wrenched or 
 torn in sprains of the knee. 
 
 The ligamentum patellae may be torn either from 
 its lower attachment to the tubercle of the tibia or 
 from the patella above. In each case it is usual for 
 a small fragment of bone to be detached with it. 
 In rare cases it snaps across near its middle. It may 
 be incompletely torn. The diagnosis is by no means 
 difficult, for the patella is usually displaced and 
 drawn upwards above the knee. When very small 
 fragments of bone are detached, nothing but the 
 X-rays will make the diagnosis certain. It is usual 
 to regard this injury of as much serious consequence 
 as a fracture of the patella. 
 
 As to treatment, posture and fixation is a very un- 
 certain method, and as the cavity of the knee-joint 
 is invariably torn into, as is the case in fractures 
 
MUSCLES AND TENDONS 203 
 
 of the patella, the joint is filled with blood. Whenever 
 there is no insuperable objection to an operation it 
 is best to open the joint and to suture the ligament 
 accurately with catgut. The writer has used this plan 
 in four recent cases with the greatest satisfaction. 
 All except one could walk freely and bend the knee 
 well beyond the right ankle in the space of five weeks. 
 The other, a timid boy, did not obtain full move- 
 ments until ten weeks after the operation, but this 
 was chiefly because he would not exercise the limb 
 when left to himself. The technique is the same as 
 for suture of fractured patella, an operation which 
 the writer now invariably performs, by using catgut 
 instead of wire. The accompanying Figs. 59 and 60 
 illustrate a case in which both the ligaments were 
 torn at the same time in a man who, having slipped, 
 tried to save himself from falling backwards. His 
 case was subsequently treated elsewhere for months 
 by posture and splints, with the result that there was 
 no union on either side. He has, however, been able 
 to walk with the aid of a somewhat cumbrous appli- 
 ance, also depicted in Fig. 61. The case was not 
 considered suitable for operation owing to his age 
 and alcoholic habits. 
 
 * Lawn-tennis leg ' has been variously attributed 
 to rupture of the plantaris tendon, to rupture of 
 fibres of the soleus, and even to an injury to the deep 
 veins situated between the muscles of the calf. That 
 sometimes the symptoms are due to the rupture of 
 one muscle, and at others to another, there seems 
 little doubt. The writer has seen cases in which he 
 attributed the symptoms to a separation of some of 
 the fibres of the soleus muscle from the oblique line 
 
204 INDIVIDUAL INJURIES TO 
 
 of the tibia. The symptoms are sudden pain, often 
 described as if the individual had been struck by 
 a stone thrown at him, or cut with the lash of a whip, 
 followed by an inability to walk, and later by swelling 
 of the calf. The diagnosis is made from the history 
 of the case taken together with the symptoms. 
 The most suitable treatment is to strap the leg 
 
 Fig. 59. Old case of double rupture of the patellar ligaments. The 
 patient had met with the accident many years before, from trjring to 
 save himself from falling backwards after slipping in the street. He was 
 able to walk with the aid of a hinged apparatus worn on each knee. The 
 characteristic flexion of both joints as the result of loss of power in the 
 extensors as well as the subsequent contraction of the hamstrings is well 
 shown. Patient refused operation. Mr. R. H. Sankey kindly procured 
 the patient, and made the illustrations for the author. 
 
 from two inches above the ankle up to a level two 
 or three inches below the knee, by means of stout 
 rubber plaster, and then of allowing the patient to 
 walk about, making a point of keeping his heel flat 
 upon the ground all the time. A flat, low-heeled 
 boot is best; even running may be permitted in a few 
 days with this line of treatment ; active exercises 
 
MUSCLES AND TENDONS 
 
 205 
 
 should not, however, be permitted until all or most 
 of the swelling has disappeared. The subsidence or 
 not of the swelling is the best guide as to the com- 
 mencement of active exercises. The strapping should 
 be removed and re-applied as often as it becomes 
 loosened by the absorption of the effused blood 
 
 Fig. 60. Radiogram of case of ruptured patellar ligament of long 
 standing to show tlie displacement of the patella upwards from the front 
 of the joint to the anterior surface of the femur. Taken from the same 
 case as is described in the text. 
 
 beneath it. The prognosis is invariably good, and 
 the patient should be free from all symptoms in 
 from a fortnight to three weeks. 
 
 When, however, the injury is due to tearing of the 
 fibres of the soleus, recurrences may be met with, 
 though they are not common. 
 
206 INDIVIDUAL INJURIES TO 
 
 The tendo-Achillis is often ruptured from one to 
 one-and-a-half inches from its attachment to the os 
 calcis as the result of sudden violent strain. The symp- 
 toms are so slight that many cases are on record in 
 which the individual walked about afterwards for 
 even considerable distances with but little pain and 
 
 Fig. 61. To show the apparatus worn for many years by a patient, 
 the subject of rupture of the patellar Ugament on both sides. He was 
 able to walk with tolerable comfort. 
 
 inconvenience. A feeling of weakness in the ankle, 
 whenever she got on her toes, was all that was com- 
 plained of by a young lady of eighteen, who ruptured 
 this tendon last year in jumping out of a punt. When 
 she first presented herself for inspection she limped 
 slightly into the room and seemed to have little or 
 
MUSCLES AND TENDONS 
 
 207 
 
 no pain. On making an examination, eighteen hours 
 after the accident, there was found considerable 
 ecchymosis over the region of the heel, and a distinct 
 gap could be made out at the narrowest part of the 
 tendon. There was tenderness on pressure over all 
 
 Fig. 62 represents a leg that has been strapped for tearing of some 
 of the fibres of the soleus muscle. The strapping has been too tightly 
 applied below. To prevent constriction, the lower strap should be appUed 
 over a piece of folded lint or proper padding. 
 
 the muscles of the calf. Whenever the ankle was 
 bent, the feeling of discomfort was increased and 
 the gap in the tendon became more evident. The 
 case was treated in the usual textbook fashion, by 
 means of a laced shoe, to the heel of which an elastic 
 
208 INDIVIDUAL INJURIES TO 
 
 apparatus was fixed. The elastic band was then 
 passed upwards to be attached to a broad leather 
 strap which fitted accurately the middle of the thigh 
 and was so arranged that the heel was drawn towards 
 the knee and the toes pointed. This allowed of com- 
 plete relaxation of the muscles of the calf. The 
 apparatus was worn for fourteen days and then 
 removed. After this, gentle muscular exercise was 
 allowed while she lay on the sofa, but the f uU weight 
 of the body was not permitted until twenty-eight 
 days had passed. When she first began to walk she 
 complained of a feeling of insecurity, but this passed 
 off in two or three days, when she expressed herself 
 as being not only able to walk but to run. 
 
 John Hunter ^ is said to have ruptured his tendo- 
 Achillis. The accident occurred when he was aged 
 thirty-nine, while dancing. ' He did not confine 
 himself to bed, but continued to walk during the 
 cure.' He kept the heel raised, and compressed the 
 muscle gently with a roller. He is said, however, to 
 have experienced ossification of his tendon. It is 
 interesting here to note that so long ago as Hunter's 
 time it was considered sound practice to allow a 
 patient to walk about with a torn tendon, providing, 
 however, that it was strapped and supported. The 
 fact that ossification of the tendon supervened had 
 nothing to do with the method of the treatment, 
 is the present writer's opinion; it was simply an 
 example of the unavoidable sequelae of a sprain, to 
 which reference has already been made. Do what 
 the surgeon may, in certain cases of articular sprain, 
 osteo-arthritis will supervene, and in muscular strains, 
 1 Palmer, Life, p. 34. 
 
MUSCLES AND TENDONS 209 
 
 myositis ossificans. These untoward effects are so 
 far regarded as non-preventable. Every surgeon is 
 aware of the ready way in which tendons unite after 
 tenotomy, and many will have seen old cases of 
 rupture through tendons, where very fair union has 
 taken place, in animals and persons who had received 
 but scanty treatment, and where walking and other 
 exercises have been permitted, or at any rate been 
 indulged in. The writer has recently made dissections 
 of two such specimens, one in a horse and the other 
 of the tendo-Achillis of a dissecting-room subject. 
 The blood-clot which fills the intervening space in 
 the tendon-sheath readily organizes, and will do so 
 whether the tendons are put at rest or whether they 
 are exercised or moved from the beginning. Pro- 
 longed fixation by apparatus is, as a rule, quite 
 unnecessary. If non-union should occur, and the 
 disability is great, an open operation, with suturing 
 the ends of the tendon, can be at any time performed. 
 It is a safe and comparatively simple matter. There 
 are many instances on record of the successful 
 suturing of tendons ; indeed, such is an everyday 
 occurrence. 
 
 The treatment consists in strapping the whole 
 length of the tendon firmly to the bones of the leg, 
 by encircling strips of plaster, and of allowing the 
 individual to walk about with a somewhat raised 
 heel as soon as the tendency to swelling has ceased. 
 The writer has been much interested in discovering 
 that the treatment which he has been in the habit 
 of employing for sometime in these cases, is precisely 
 similar to that which was advocated by John Hunter 
 many years ago. 
 
 WHITELOCKE ' p 
 
CHAPTER IX 
 
 MASSAGE, MOVEMENT AND EXERCISES IN 
 THE TREATMENT OF SPRAINS AND BRUISES 
 
 From time immemorial rubbings and movements 
 have been used for the rehef of stiffness and pain in 
 joints. The practice, Hke many other things, seems 
 to have originated in the East. Formerly much in 
 vogue in this country, for a time it almost dropped 
 out, only to be revived in recent times with renewed 
 vigour and unabating popularity. The system is 
 the chief asset of the itinerant quack and everwise 
 bone-setter ; and, like most good things, it is liable 
 to be abused. 
 
 Massage and movements, when employed in the 
 cure of disease, are surgical procedures, and as such 
 should only be used under the supervision and 
 guidance of persons trained in surgical methods. 
 Unless some such Umitations are imposed, harm will 
 result. To take a single example, what could be 
 more baneful than the daily rubbings of a joint 
 swollen and full as the result of early tubercular 
 infection ? 
 
 Before proceeding further, it may be useful to 
 discuss the so-called ' physiology of massage '. The 
 various movements of massage undoubtedly improve 
 the nutrition of an injured part by primarily increas- 
 ing its blood-supply. By gentle friction massage the 
 local blood-vessels become dilated, and fresh oxy- 
 
MASSAGE, MOVEMENT AND EXERCISES 211 
 
 genated blood is brought ; it is easy to satisfy one 
 as to this, for not only does the skin of a joint 
 formerly cold and pale become reddened, but it is 
 warmer to the touch. By experiment, Brunton and 
 Tunnicliffe demonstrated that not only does more 
 blood pass through the muscles in a given time while 
 they were being massaged, but that the increased 
 flow lasted for some time after. Doubtless all the 
 tissues in the neighbourhood of the injury partake of 
 the increased blood-supply and reap the advantage. 
 
 The kneading and percussion movements act me- 
 chanically in breaking up all coagulated material, such 
 as blood-clot and lymph, found amongst the muscles 
 and tendons and other tissues around an injured 
 joint ; and by dispersing the fragments over a larger 
 absorption area and into more healthy parts, aid 
 most materially in the absorption of the effete 
 material by the neighbouring lymphatics and veins. 
 Mechanically by stimulating the nerve-endings, fric- 
 tion massage would seem to reflexly produce a dila- 
 tation of the vessels of the part. In that way it 
 increases the blood-flow through the muscles and 
 other tissues. It has a decided influence in diminish- 
 ing pain, for most persons will have experienced the 
 soothing effect it has if applied gently to a painful 
 spot. This effect is probably due to some reflex act, 
 for the relief follows on too quickly to be explained 
 by any direct effect it may produce upon the nerve- 
 endings themselves. Some of us may have experi- 
 enced the almost immediate relief of neuralgic pain 
 as the result of taking a hot cup of tea or a dose of 
 caffein. The action in this latter instance is doubt- 
 less due to an alteration in the circulation of the 
 
 p2 
 
212 MASSAGE, MOVEMENT AND EXERCISES 
 
 nerve-endings following upon the ingestion of a 
 rapidly diffusable stimulant. Whatever the true 
 explanation, it is a fact that massage readily relieves 
 pain when carefully applied to a strain. Muscle- 
 waste is probably in a measure prevented, partly by 
 a direct stimulation of the nerves of supply and 
 partly by indirectly increasing the local blood-supply. 
 
 It promotes the absorption of effused materials, 
 whether they are enclosed in the synovial cavities 
 or are extravasated diffusely into the tissues generally. 
 
 Limitations of massage. The immediate use of 
 massage in sprains, either with or without passive 
 movement, which it should at all times precede, is 
 a practice much in vogue at the present time. By 
 some surgeons it is adopted from the very beginning 
 of the treatment and kept up until even long after 
 recovery is complete. While in no way wishing to 
 under-estimate the value of massage, especially in 
 long-standing cases and in the later stages of ordinary 
 cases, the writer is strongly of opinion that its imme- 
 diate use, in the large majority of cases, is not only 
 not necessary but may be even harmful. This state- 
 ment requires some explanation. 
 
 It is an everyday experience that cases such as 
 those in which a cutting operation has been per- 
 formed, or in which, from the presence of some 
 abrasion or wound of the skin, local massage was 
 impracticable, get on just as well and recover quite 
 as quickly in the end as those in which rubbing was 
 applied from the very first. 
 
 Again, it is an undoubted fact, that, given a joint 
 with commencing effusion, rubbing, however gently 
 performed, will at once increase the extravasation. 
 
IN THE TREATMENT OF SPRAINS, ETC. 213 
 
 and if persevered in for any length of time will lead 
 to marked increase of tension and even pain. 
 
 Nor is it difficult to understand that a haemorrhage 
 resulting, say, from laceration of a large muscle like 
 the crureus or rectus abdominis will be increased 
 by manual manipulation, and this is just what 
 actually does take place when immediate massage is 
 applied to any large collection of blood. 
 
 Massage should not be used until the effusion in 
 a joint has ceased to increase, and never till all risk 
 of encouraging and promoting haemorrhage has 
 passed. 
 
 It must be applied with extreme caution in all 
 cases in which there is any likelihood of constitutional 
 disease appearing as a complication. Such diseases 
 as gout, tuberculosis, haemophilia, acute or sub- 
 acute rheumatism, are especially likely to be made 
 worse by such treatment. The main indications are 
 found in 
 
 1. All cases of strain or sprain without swelling. 
 
 2. All articular sprains, after the effusion has dis- 
 appeared or has nearly disappeared either spon- 
 taneously or after treatment with elastic pressure. 
 
 3. Muscular sprains, when all risk of increasing 
 the swelling has passed. 
 
 4. All old, long-standing, chronic cases, where 
 pain, stiffness, swelling, matting together of the 
 tissues, or atrophy, exist. 
 
 It is useful for muscular as well as articular sprains. 
 
 In sprains complicated hy fracture, separation of 
 epiphyses, and displaced inter-articular cartilages, it 
 must be very cautiously employed. 
 
 If the movements increase the pain rather than 
 
214 MASSAGE, MOVEMENT AND EXERCISES 
 
 diminish it, they should be withheld, at any rate for 
 a time. It is unusual for pain to be increased in 
 ordinary eases, so that when massage is uncomfort- 
 able and badly borne some complication may be 
 suspected. 
 
 Passive movements are of more limited applica- 
 tion, should be employed as an assistant to massage, 
 and always follow, never precede it. The movements 
 are mechanical in character and are of service chiefly 
 in restoring to their natural positions tissues that are 
 torn and displaced, in stretching or breaking down 
 recent adhesions, and in preventing the formation 
 of new adhesions after old ones have been forcibly 
 torn asunder in the treatment of stiff and ankylosed 
 joints. 
 
 It has been stated that they assist in the absorp- 
 tion of extra vasated material, but this is doubtful ; 
 they certainly have no influence in preventing mus- 
 cular atrophy. The contra-indications are precisely 
 those of early massage. 
 
 In sprains with fracture, when there is a proba- 
 bility that active voluntary movements would pro- 
 duce a separation of the fragments, passive movements 
 are preferable to active. Even in this class of cases 
 they must be employed with much caution, and 
 whenever it is convenient the surgeon himself should 
 carry out the manipulations. 
 
 Active or voluntary movements act physiologically 
 and are of the very greatest service. Their applica- 
 tion is almost universal, and, with certain simple and 
 rare limitations, may be employed at all stages and 
 in all conditions of sprain whether articular or 
 muscular. 
 
IN THE TREATMENT OF SPRAINS, ETC. 215 
 
 A voluntary movement implies the passage of 
 a voluntary nervous impulse such as controls the 
 whole process of nutrition in the tissues of the body. 
 The several indications that require surgical assis- 
 tance, such as the presence of extravasated material 
 within or around a joint, the formation of adhesions, 
 stiffness as a consequence of matting of the tissues 
 together, and muscular atrophy, may all be removed 
 by muscular movements. 
 
 All that massage and passive movements are said 
 to be capable of effecting may be more speedily 
 and efficiently attained by means of elastic pressure 
 combined with voluntary movements executed either 
 simply or against resistance. 
 
 Elastic pressure, as explained when dealing with 
 the treatment of effusion in another chapter, is the 
 surest and safest means which we possess for attain- 
 ing rapid and complete absorption of fluids. It has 
 all the advantages claimed for massage in early 
 treatment, without any of its disadvantages, and 
 when combined with active movements, may be 
 described for all practical purposes as ideal. For by 
 mechanically and rapidly removing the effusions and 
 passing them on again into the general circulation, 
 tension is diminished, pain relieved, adhesions pre- 
 vented, and taken conjointly with muscular move- 
 ments, which alone can prevent muscular atrophy, 
 meets every ordinary desideratum. 
 
 In urging early voluntary movements it must be 
 understood that it is not suggested that all the 
 muscles of an injured part should be exercised, or 
 that they should be vigorously moved ; for, on the 
 contrary, it is of the greatest importance that the 
 
216 MASSAGE, MOVEMENT AND EXERCISES 
 
 movements at first should be of the gentlest possible 
 kind, and only just sufficient to ensure the passage 
 downwards of nervous impulses. It is also important 
 that until repair is fairly advanced, the particular 
 muscles that have borne the brunt of the incidence 
 of the violence should be subjected to very little or 
 no strain, while the neighbouring muscles, tendons, 
 and ligaments are freely exercised. 
 
 In the later stages of treatment, and especially in 
 neglected sprains, definite muscular exercises and 
 movements often against resistance are of the greatest 
 possible service in restoring movement, preventing 
 atrophy, and assisting in the regeneration of muscles 
 already wasted. 
 
 Various gymnastic exercises, performed with or 
 without the aid of mechanical contrivances, have 
 been instituted for promoting the development and 
 regeneration of muscles, and for removing stiffness 
 and incapacity. 
 
 Forcible movements of stiff joints under an 
 anaesthetic. These should never be undertaken until 
 a careful diagnosis has been made ; which is often 
 only arrived at after much trouble and difficulty. 
 Unless the surgeon is prepared to bring into play his 
 most discriminating powers, he may do as much 
 harm as the bone-setter who, in a routine way, treats 
 everything by movement. Movements under an 
 anaesthetic find their chief utility in healthy joints, 
 and they for the most part act mechanically. For 
 the replacement of inter- articular cartilages, stretch- 
 ing or breaking down synovial adhesions, restoring 
 lacerated portions of a capsular ligament to their 
 natural situations, altering the angle in which 
 
IN THE TREATMENT OF SPRAINS, ETC. 217 
 
 a joint may become fixed, they are of special 
 value. 
 
 If the joint, however, has already undergone any 
 definite organic change in its structure, such as may 
 result from Charcot's disease or other forms of osteo- 
 arthritis, or if the stiffness is mainly due to the taint 
 of some such constitutional affection as tuberculosis, 
 chronic rheumatism, of gout or pyaemia, it is quite 
 unsuitable for any forcible movement. The con- 
 ditions in which most good may be expected are those 
 in which a joint is stiff or even painful because its 
 action is hampered, not by any disability within the 
 joint itself, but owing rather to the matting together 
 of its surrounding tissues by unabsorbed extravasated 
 material. The shoulder, as we have seen, is, of all the 
 joints, the one which affords the best example of such 
 a state of affairs, and it is the one from the treatment 
 of which the surgeon is most likely to gain satis- 
 faction. 
 
 Stated broadly, it may be said that the results of 
 forcible movement are not as good as we may be led 
 to expect from theoretical considerations, that they 
 are often very disappointing, and will assuredly be 
 even disastrous unless employed only after the 
 strictest discrimination and selection, and with the 
 greatest care and skill in management. 
 
 Pain and stiffness are the general indications for 
 forcible movement in a joint. It is often a difficult 
 matter to decide at once whether a joint is or is not 
 suitable. A good and serviceable plan is to carefully 
 investigate the range of movement and to notice 
 whether the pain is experienced when only a wide 
 range is attempted, or whether it is felt during every 
 
218 MASSAGE, MOVEMENT AND EXERCISES 
 
 movement, however slight. Thus a shoulder crippled 
 for months, with shining surface, atrophied deltoid, 
 and apparent absolute fixity, painful whenever any 
 extensive movements are attempted, may prove, 
 after close investigation, to be eminently suitable. 
 When the movements, if ever so limited in range, are 
 smooth and afford no sensation of roughness or jarring, 
 one may be fairly confident that the trouble is outside 
 the joint and not within it. A joint with perfectly 
 smooth movements is rarely, if ever, disorganized or 
 organically wrong. 
 
 So long as the stiffness is outside the capsular 
 cavity and is mainly concerned with the structures 
 around the joint, forcible movements may be under- 
 taken with every prospect of complete success. 
 
 Simple means adopted by the author for prevent- 
 ing muscle-wasting by using gentle active exercise. 
 For developing the muscles of a thigh and leg that 
 have atrophied as the result of prolonged fixation in 
 splints, the following manoeuvre has proved of great 
 service in many recent cases. It is of more certain 
 value than are the movements against resistance as 
 practised in gymnasia with the aid of pulleys and 
 elastic apparatus. It consists, when practicable, in 
 making the patient assume the squatting position. 
 In this posture the hip, knee, ankle, and mid-tarsal 
 joints are all flexed, the hamstrings are relaxed, while 
 the extensors of the thigh are fully stretched. The 
 ligamentum patellae is held taut all the while. During 
 flexion of the mid-tarsal joint the muscles of the calf 
 are stretched by the fixity of the tendo-Achillis 
 below, while the muscles of the front of the leg are 
 also put on the stretch. At the commencement of 
 
IN THE TREATMENT OF SPRAINS, ETC. 219 
 
 treatment this is all that is necessary, and the 
 squatting position may be assumed for two or three 
 minutes at a time, three or four times in a day. In 
 this way all those tissues which, while retained in 
 the extended position were relaxed and placed at 
 rest, are now put upon the stretch and exercised. 
 It is surprising with what rapidity restored power 
 begins to show itself with the assistance of this 
 simple plan. As soon as the erect, or even the sitting 
 position is resumed after squatting, a sense of relief 
 is immediately felt, and a feeling as of work done is 
 experienced. This simple device of stretching the 
 muscles, tendons and ligaments by squatting, brings 
 into play nervous and other stimuli which were 
 wanting in a limb made to assume for a prolonged 
 period the extended position. The natural stimula- 
 tion thus brought about in the muscles which for 
 weeks, or longer, had been thrown out of use, i& 
 most beneficial. The individual experiences at once 
 a feeling of increased warmth and renewed vigour in 
 the limb. After the squatting has been practised 
 for a few times, the patient should be encouraged to 
 raise himself gently on to his toes as in attempting 
 to rise. A little more time should be devoted to this 
 each day, until by degrees he is able to raise himself 
 completely to the erect posture, and to carry out the 
 exercises of alternately squatting and rising, slowly 
 and gradually. This should be continuously prac- 
 tised till the limb becomes again strong and the 
 muscles regenerated. 
 
 These principles of graduated exercise may be 
 adapted with equal advantage to the muscles of the 
 upper extremity, or indeed to any muscles in the body. 
 
220 MASSAGE, MOVEMENT AND EXERCISES 
 
 The means whereby the individual is enabled to 
 fully exercise his muscles by lifting his own body 
 weight are not only more easily and conveniently 
 employed, but they seem to be more rapidly effi- 
 cacious than are the stock exercises by means of 
 weights and pulleys, so often recommended. 
 
 The movements when carried out naturally, and 
 gradually and carefully increased, may be said to be 
 ideal in their results. An improved nutrition is the 
 first sign of progress, and this is soon succeeded by 
 true regeneration and growth. At first, both limbs, 
 the sound as well as the affected, should be made to 
 execute the movements, and as improvement takes 
 place, the unsound limb should be made to do more 
 and more in proportion. The natural and voluntary 
 impulses thus sent down from the brain to the 
 muscles on both sides at the same time that muscular 
 efforts are made, would seem to promote more 
 readily the regeneration of muscle-tissue than does 
 any more mechanical plan of action, such as pulling 
 or working against resistance. With such a plan of 
 treatment, gymnasia are unnecessary, and all that is 
 required is a thorough understanding between the 
 surgeon and his patient as to the simplest means by 
 which healthy physiological movements may be 
 executed. 
 
 As a preventive of muscle-wasting the writer knows 
 of no method which even approaches this in its results 
 either as to efficiency, simplicity, or rapidity. 
 
 Movements and exercises against resistance. No 
 one will gainsay the importance of exercising weak- 
 ened or stiff muscles by means of weight-lifting or 
 other methods in gymnasia, as often without some 
 
IN THE TREATMENT OF SPRAINS, ETC. 221 
 
 such means cases go from bad to worse ; but it is here 
 contended that these systems will be less and less 
 required as the more rational treatment of sprains 
 becomes more and more universally adopted. A 
 sprain properly treated in the first instance will 
 rarely, if ever, require gymnasium treatment. 
 
APPENDIX 
 
 It has been thought advisable to add an Appendix, for 
 although most of the details are elementary and already 
 well known, there is reason to believe that they may prove 
 useful to some practitioners. 
 
 Of local applications, the following have been found 
 useful : — 
 
 The ordinary Soap Liniment (Linimentum Saponis) is 
 convenient for rubbing in almost all cases in which massage 
 is indicated. It provides a suitable lubricant, and prevents 
 chafing of the skin wherever friction is considerable. It 
 may be used in acute as well as chronic cases. 
 
 Iodine Liniment (Linimentum lodi) is occasionally useful 
 as a counter-irritant, and as being stronger than the tincture 
 of iodine. It has the disadvantage of being rather irritating 
 to some skins. It is most useful for painting chronically 
 inflamed joints, and in teno-synovitis. 
 
 Terebine Liniment (Linimentum terebinthini Acetici) is a 
 rubrifacient and mild counter-irritant when rubbed in. It is 
 useful in strains of both muscles and joints where there is 
 little or no swelHng. It may also be used in joints that are 
 chronically painful. 
 
 Vasogen-Iodine is par excellence the most useful applica- 
 tion. It possesses all the advantages of the liniment of 
 iodine without its disadvantages. May be used almost 
 universally for acute as well as chronic cases, and causes 
 little or no irritation. 
 
 Tincture of Iodine is of little real value ; it is apt to 
 irritate or harden the skin, and is inferior both to the 
 liniment and vasogen-iodine. It is sometimes useful in 
 the mildest cases, and where only a few applications are 
 required. 
 
APPENDIX 223 
 
 Scott's (mercurial) dressing is useful in sprains complicated 
 by tuberculosis, and in some very chronic forms of relapsing 
 synovitis. 
 
 BANDAGES AND STRAPPING. 
 
 Plain rubber bandages are not recommended. They are 
 too powerful, often produce pain, are hot, allowing little or 
 no evaporation, and if long continued or constantly worn, 
 tend to deplete the part of its proper blood-supply, and 
 thereby lowering its nutrition, and producing muscle- was ting 
 and enfeeblement. 
 
 Elastic Webbing (of from 2 to 2 J inches in width) is more 
 useful as a supporting-bandage, and should be substituted 
 for the plain rubber bandage. Such a bandage is chiefly 
 useful as a support, either in the early convalescence or on 
 the return to athletic exercises. It should never be worn 
 continuously, and should at least be removed during the 
 night. Being elastic, it prevents the natural and proper 
 circulation in the part. 
 
 Elastic Knee-caps and Anklets are helpful more as a 
 placebo than any definite means of support. The athlete, 
 on his return to sport, is kept ever mindful of its presence 
 as well as of its meaning. They may be employed during 
 active and violent exercises when these are first resumed 
 after an injury, but should be removed as soon as the exer- 
 cises are over. They must not be worn continuously or 
 for any considerable time, and as a rule should be avoided 
 whenever possible. 
 
 Leather straps to the wrist are not recommended. 
 
 Instruments for preventing displacement of the semilunar 
 cartilages, and highly recommended by some, should be 
 avoided as much as possible. They eventually lead to 
 atrophy of the thigh muscles, and are only helpful to those 
 who, for some definite reason, are unable to undergo an 
 operation. That they retain the cartilage in position is 
 absurd, since the structure is almost invariably displaced 
 
224 APPENDIX 
 
 inwards into the inter-condyloid notch and almost never 
 outwards. 
 
 Their action depends entirely on reducing the knee to a 
 hinge, disallowing all rotation, and the general utility 
 depends upon the accuracy of the fit of the circular bands 
 around the thigh and leg. The hinge of the apparatus 
 readily allows of flexion and extension. 
 
 The small ' Spring trusses ' for the knee, advertised and 
 recommended in some quarters, are absolutely useless, since 
 they are worn on the assumption that the semilunar cartilage 
 is displaced from the knee. This is a fallacy, readily ex- 
 posed both by pathological data and clinical experience. 
 
 It may here be stated as a general dictum, that every 
 apparatus or appliance that can be dispensed with should 
 be done away with on the earliest possible occasion when 
 dealing with injured joints. 
 
 Of Plaster for strapping • 
 
 several kinds are useful, none are ideal. The essentials 
 of a good plaster are strength, a rubber base to prevent 
 slipping, and perforations to allow of evaporation from the 
 skin. 
 
 The plaster made by Messrs. Ewen and Sons, and spread 
 upon chamois leather, is an excellent strapping, but it is 
 rather expensive and somewhat irritating unless removed 
 frequently. 
 
 Johnson and Johnson's * Z ' (Zinc Oxide) plaster is 
 very useful. It causes less irritation than most others, and 
 is sufficiently firm. 
 
 * Leucoplast ' or White Rubber adhesive plaster (Pilot 
 Brand) is useful. It answers most requirements, and is not 
 expensive. 
 
 Seabury's Rubber Adhesive Plaster, when perforated, is 
 particularly useful for strapping the muscles of the thigh ; 
 but, even though it is perforated and allows of some evapora- 
 tion, will produce irritation if left on for more than a few 
 days. 
 
APPENDIX 
 
 225 
 
 In applying strapping, certain details must be attended 
 to if success is to be attained. The limb or part of the body 
 to be strapped must be cleanly shaved, then washed with 
 soap and warm water, and subsequently cleansed with 
 ether or benzine, and carefully dried. This is essential if 
 the plaster is to remain in situ for several days. 
 
 The accompanying plates are illustrative of the writer's 
 plan of strapping some of the commonest sprains in the body. 
 
 Fig. 63. Photograph of ankle strapped for strain by author's method. 
 
 In strapping for a sprain of the chest (intercostal muscles). 
 Fig. 56 A, the strips of plaster should be from 1 J to 2 inches 
 wide, and made long enough to encircle the body to at least 
 two-thirds of its circumference. Each horizontal strip, 
 beginning from above and passing downwards, should cover 
 half of the one immediately above it, and must be applied at 
 the end of the act of expiration. The strapping should 
 extend for some inches both above and below the injury. 
 
 In ' Bowler's side ', Fig. 56 b (strain of the obKque abdominal 
 muscles), the same plan as the above should be adopted, 
 
 WmXELOCKE n 
 
226 APPENDIX 
 
 and the strapping should extend from three inches above 
 the level of the twelfth rib to well below the iliac crest. 
 
 The rectus abdominis (Fig. 55) is best strapped with a wide 
 piece of Ewen's chamois leather plaster extending from the 
 upper thigh, passing by Poupart's ligament, to the front of 
 the chest wall and slightly across the middle line of the body. 
 
 FiQ. 64. To illustrate plan of strapping the shoulder for contusion or 
 sprain. The axilla should be well padded, and the plaster extend to the 
 middle line of body. 
 
 Small overlapping strips may, however, be employed with 
 equal efficiency. 
 
 The muscles of the thigh (extensors, adductors and ham- 
 strings) are conveniently supported by a wide strip of 
 Seabury's perforated plaster, not less than six inches in 
 width, and made to encircle the limb for the greatest part 
 of its circumference. It should not be made to meet, how- 
 ever [vide Fig. 58), or the muscles may be torn during 
 vigorous contractions. 
 
APPENDIX 
 
 227 
 
 The muscles of the calf (soleus and plantaris) are strapped 
 from below upwards, beginning at the smallest part of the 
 leg and extending up to two inches below the knee. The 
 strips of plaster will vary in width according to the size of 
 the limb, and overlap from below upwards. The limb 
 should always be depleted of as much blood as possible, by 
 
 Fig. 65. 
 effusioiiv 
 
 An elbow- joint with elastic pressure applied for sprain with 
 
 elevating it before the strips are laid on. Unless this 
 precaution is taken, the plaster will soon become loosened 
 by reason of the absorption of the blood which was effused. 
 
 Strapping of the knee, ankle, and feet is done on general 
 principles. 
 
 The deltoid and shoulder region should be accurately 
 strapped by means of a spica, the ends of the plaster extend- 
 
 Q2 
 
228 APPENDIX 
 
 ing to the middle line of the body, both before and behind ; 
 while the axilla must be carefully padded with thick layers 
 of wadding. 
 
 The other joints of the upper extremity, such as the elbow, 
 wrist, carpo-metacarpal and inter-phalangeal, are dealt with 
 on general lines. 
 
 The figures show also, in a graphic way, the method of 
 applying elastic pressure to the knee- and elbow-joints ; the 
 details of the process having been described in chapter ii. 
 
 The application of high degrees of temperature to sprains 
 has, in the hands of some, met with much favour. Radiant- 
 heat baths are extolled by some surgeons ; but the writer's 
 limited experience of the treatment does not fill him with 
 much enthusiasm. 
 
 The injection of Fihrolysin for the removal of adhesions 
 and as a means of rendering stiff joints more supple and 
 movable is a new departure and seems to promise well. 
 The writer's experience in this field is somewhat limited, but 
 as far as it goes, it leads him to be hopeful. The data at 
 the present time are hardly sufficient to allow of any dog- 
 matic statement. It is possible that a more extensive ex- 
 perience may even diminish present enthusiasm ; time alone 
 will prove the efficacy or otherwise of this our latest nostrum. 
 
INDEX 
 
 Acromio-clavicular joint, sprains of, 
 75. 
 causes of, 75. 
 
 symptoms, diagnosis, and treat- 
 ment of, 75. 
 guarded prognosis in, 75. 
 Active voluntary movements, in 
 treatment of sprains, 26, 81, 
 214. 
 early uses and advantages of, 26, 
 
 214, 216. 
 limitations of, 214, 216. 
 physiological action of, 214. 
 method of employment, 214. 
 Acute traumatic sjniovitis of knee, 
 treatment of, 116. 
 prognosis of, 116. 
 Adductor longus muscle, 43, 62. 
 rupture of, 201. 
 causes, symptoms, diagnosis, and 
 treatment of, 201. 
 Adductor magnus tendon, strain of, 
 
 202. 
 Albuminuria, as a complication of 
 
 sprains, 19. 
 Anaesthetics, in treatment of sprains, 
 14. 
 contra-indications of, 14. 
 for diagnosis, 33. 
 uses of, in aspiration, 33. 
 use of, in synovitis, 45. 
 Anatomy, general, of joints, 2. 
 
 surgical, of knee-joint, 109, 113. 
 ' Angler's elbow,' 170. 
 Ankle-joint, sprains of, frequency of, 
 102. 
 surgical anatomy of, 102. 
 causes of, 102. 
 complications in, 102, 106. 
 differential diagnosis of, 103. 
 prognosis and treatment of, 103, 
 
 105. 
 sprain-fracture of, 103. 
 symptoms of, 103. 
 
 Ankle-joint, sprains of, method of 
 strapping in, 103, 223. 
 advantages of elastic pressure in, 
 
 105. 
 after-treatment of, 105. 
 Ankylosis, as sequela of sprain- 
 fracture, 41. 
 causes of, 56. 
 treatment of, 56. 
 Annandale, Professor, the late, 163. 
 Anterior annular ligament, 102. 
 Anterior crucial ligament of the 
 
 knee. 111, 131. 
 Apparatus for preventing displace- 
 ment of semilunar cartilage, 
 223. 
 Appendix, 222. 
 Arthritis deformans, 67. 
 Arthrotomy, in treatment of joints, 
 34. 
 and temporary drainage of joints, 
 
 34, 48, 162. 
 for digital exploration in recur- 
 rent synovitis, 34. 
 temperature charts in, 47, 158-61. 
 author's operation for, 153. 
 for removal of cartilages and 
 loose bodies, 153. 
 Articular sprains, 8. 
 classification of, 9. 
 individual articular sprains, 74. 
 Articular vessels, 3. 
 Aspiration, in treatment of synovitis 
 and tension in joints, 33. 
 special advantages of, 33. 
 indications for, 33. 
 for large blood extravasations, 79. 
 Aspirin, in treatment of nerve pain, 
 
 53. 
 Athletics, as a factor of sprains, 6. 
 Atrophy of muscles, acting on joints, 
 2,43. 
 as a sequela of articular sprains, 
 41. 
 
230 
 
 INDEX 
 
 Atrophy of muscles, as the result of 
 
 nerve injury, 43. 
 from prolonged fixation in splints, 
 
 43. 
 means adopted for preventing, 81. 
 treatment of, by active voluntary 
 
 movements and exercises, 215, 
 
 216. 
 
 Bandages, ' crepe velpeau ', 23, 28. 
 advantages of intermittent re- 
 moval and reapplication of, 24. 
 special, domette, elastic webbing, 
 
 plain rubber, 23, 223. 
 spica, use of, in sprain of shoulder- 
 joint, 78. 
 Bennett, Professor, of Dublin, 96. 
 Bennett, Sir William, 123, 139. 
 Biceps brachialis, rupture of, 190. 
 Biceps cruris muscle, rupture of, 200. 
 Biceps flexor cubiti muscle, rupture 
 of, 192. 
 diagnosis and treatment of, 192, 
 193. 
 Bicipital groove, 192. 
 Blistering in treatment of nerve 
 
 lesions, 37. 
 
 Bone-setters, treatment of sprains 
 
 by indiscriminate movements 
 
 and rubbings, 1, 6, 7, 36, 181. 
 
 Bones entering into formation of 
 
 joints, 2. 
 ' Bowler's side ', 170, 183, 189. 
 method of strapping for, 225. 
 Brachial plexus, injuries of, 13. 
 Breaking-down, in treatment of 
 ankylosis, 56. 
 in treatment of stiff shoulder- 
 joint, 80. 
 Brunton, Sir Lauder, Bart., 211. 
 
 * Calcareous deposition ' in muscles, 
 63. 
 in detached semilunar cartilage, 
 * 71. 
 
 possible forerunner of other osteo- 
 arthritic changes, 71. 
 Calico bandage, 23. 
 Callus, in sprain-fracture, increased 
 by movement and friction, 1. 
 Callus-formation at seat of frac- 
 tures, 60. 
 Capsular ligament, structure of, 2. 
 linings of, 2. 
 
 Capsular ligament, endothelium 
 of, 2. 
 of sterno- clavicular, 74. 
 of shoulder, 76. 
 of knee-joint, 108. 
 Carpal bones, fracture of, 86. 
 
 cases illustrative of, 89, 90, 91. 
 Carpal joints, 4. 
 Carpo-metacarpal joints, injury of, 
 
 in sprains of thumb, 95, 96. 
 Cartilage : semilunar cartilages of 
 knee, anatomy of, 131, 132,134. 
 displacement of internal semi- 
 lunar, 70, 125, 126, 129. 
 symptoms and clinical characters 
 
 of, 135. 
 differential diagnosis of, 137. 
 author's method for reducing 
 displacement, 139-40. 
 displaced semilunar, treatment of 
 recurring or relapsing dis- 
 placement of, 149. 
 operative treatment of, 150. 
 preliminaries to operation, 152. 
 author's operation for, 153. 
 hyaline, growth of, in detached 
 portions within the capsule of 
 a joint, 69, 147. 
 loose in joints {see Loose Bodies), 
 
 70. 
 inter-articular, 5. 
 Cases illustrating treatment of — 
 sprains, rheumatism as a com- 
 plication of, 29. 
 ' wobbly joint ', 48. 
 ossifying myositis, 60, 61. 
 loose bodies in joints, 69. 
 fracture of scaphoid bone, 89, 
 
 90, 91. 
 fracture of metacarpal bone of 
 
 thumb, 96. 
 displacement of internal semi- 
 lunar cartilage in football- 
 player, 127. 
 longitudinal splitting of an inter- 
 nal semilunar cartilage, 129-30. 
 displaced internal sejoiilunar car- 
 tilage illustrated by tempera- 
 ture charts, 158-161. 
 displaced peroneal tendons, 175-7. 
 displacement of small tendons at 
 
 back of neck, 178-80. 
 separation of epiphysis of an- 
 terior inferior spine of ilium, 1 94. 
 
INDEX 
 
 231 
 
 Case illustrating treatment of rup- 
 ture of tendo-Achillis, 206. 
 Charcot's disease, 67, 217. 
 Charts, temperature, in arthro- 
 tomy, 158-61. 
 in chronic relapsing synovitis, 
 116. 
 Chronic atrophic neuritis, 12. 
 Chronic and relapsing synovitis, 
 
 treatment of, 116. 
 Clavicular joints, 4. 
 
 inter-articular cartilage of, 12. 
 Coccygodynia, a symptom in sacro- 
 coccygeal sprain, 108. 
 electrical vibration for relief of, 
 108. 
 Coccyx, fracture or dislocation of, 
 
 108. 
 Cold, in treatment of sprains, 19. 
 contra-indications of , in debilitat- 
 ing diseases, 19. 
 CoUes's fracture, 85. 
 Complications of sprains, 9, 10. 
 with injury to nerves, 12, 35. 
 with tumour, 16. 
 with rheumatism, 29. 
 with gout, 30. 
 with tuberculosis, 31. 
 Constitutional complications of 
 sprains, 30. 
 treatment of rheumatic, gouty, 
 syphilitic, and haemophilia, 30. 
 Contusions, elastic pressure in treat- 
 ment of, 20. 
 Corpora oryzoidea, 66. 
 Crepe velpeau bandages, 23, 28. 
 Crepitus, value as diagnostic sign in 
 sprain, 15. 
 occasional absence in fracture, 15. 
 present in osteo-arthritis occa- 
 sionally, 15. 
 ' Cricket shoulder ', 19, 183. 
 nature of injury, 191. 
 treatment of, 192. 
 ' Cricket thigh ', 194. 
 Crippled or deformed joint as 
 sequela of sprain, 41. 
 etiology of, 53. 
 Crucial ligaments, anatomy of. 111. 
 Crureus muscle, 60. 
 
 Deferred swelling in joints, 10. 
 Deformed joint as sequela of sprain, 
 etiology of, 54. 
 
 Deltoid muscle, 56. 
 
 oversprain of, or partial rupture 
 
 of, 43. 
 causes of wasting of, 43. 
 rupture of, 190. 
 Deltoid sub-, bursa, enlargement 
 
 of, 77. 
 Diagnosis, modern methods of, in 
 
 sprains, 14. 
 Dislocation, 4. 
 with sprain, 12. 
 
 * by elongation ', symptoms of, 82. 
 injury of wrist in, 83. 
 diagnosis of, 83. 
 treatment of, 83. 
 prognosis of, 83. 
 of semilunar cartilages, 124. 
 anatomical reasons for greater 
 frequency of internal displace- 
 ment, 138. 
 treatment of, 139, 140. 
 of tendons, 173. 
 Displaced external semilunar car- 
 tilage, 163. 
 pathology of, 163-4. 
 cases illustrative of, 163-4. 
 treatment of, 166. 
 diagnosis of, 167. 
 Displaced internal semilunar car- 
 tilage, symptoms and clinical 
 characteristics of, 135. 
 differential diagnosis of, 137. 
 causes of, 138. 
 early treatment of, 139-43. 
 popular devices for reduction of, 
 
 139-43. 
 author's special method for re- 
 duction of, 140-3. 
 subsequent treatment of, 144-9. 
 temperature charts in operation 
 for removal of, 158-61. 
 Displacement of tendons, 173. 
 biceps flexor cubiti, 174, 178. 
 peroneus brevis, peroneus longus, 
 
 173, 176. 
 short tendons of neck, 173-8. 
 tibialis posticus, 173. 
 peroneal tendons, 177. 
 Distal muscles of a joint, hyper- 
 trophy of, 50. 
 Domette bandage, 23. 
 Drainage, in arthrotomy, 48, 162. 
 for exploration of knee, 48. 
 for chronic synovitis, 49. 
 
232 
 
 INDEX 
 
 Drainage for removal of displaced 
 
 semilunar cartilage, 157. 
 ' Driver's elbow ', 169. 
 ' Drop-top ', anatomy of, 97. 
 
 symptoms of, 97. 
 
 how caused, 97. 
 
 deformity in consequence of, 97. 
 
 treatment of, 98-9. 
 
 author's operation for, 99-100. 
 Dumbbells, uses of, for developing 
 muscles, 81. 
 
 Elastic anklets, 223. 
 Elastic knee-caps, 223. 
 Elastic pressure, in treatment of 
 sprains, 20, 227. 
 principles for applying, 20, 22. 
 universal application of, in cases 
 
 of extravasation, 20, 24. 
 special advantages of, 20. 
 in tension of joints, 33. 
 in treatment of fracture-sprains, 
 
 38. . 
 in treatment of synovitis, 44. 
 advantage of, in sprains of ankle, 
 
 105. 
 compared with massage, 215. 
 Elastic pressure in treatment of 
 
 contusions, 20. 
 Elastic rubber bandage, contra- 
 indications of, in sprains, 25. 
 Elastic webbing, 223. 
 Elbow- joint, hinge of, 4. 
 sprain of, 81. 
 surgical pathology of, 82. 
 differential diagnosis, treatment, 
 and prognosis of, 82. 
 orbicular ligament of, 82. 
 treatment of sprain of, by elastic 
 compression, 227. 
 Electric vibrating machine in treat- 
 ment of sprains of the ankle- 
 joint, 107. 
 Endothelium,secretingfunctionof,2, 
 Epiphysis for anterior inferior spine 
 of ilium, separation of, 194. 
 cases illustrating, 194. 
 Evaporating lotions in treatment of 
 
 sprains and contusions, 50. 
 Exercises, indications for, in frac- 
 ture-sprain, 38, 40. 
 against resistance, 81, 220. 
 by means of weights and pulleys, 
 81. 
 
 Exploratory arthrotomy, 34. 
 
 temperature charts for, 47. 
 External lateral ligament of knee, 
 sprains of, 121. 
 
 symptoms of, 122. 
 
 prognosis and treatment of, 122. 
 External semilunar cartilage of 
 knee, anatomy of, 131-4. 
 
 displacement of, 163. 
 Extravasation, elastic pressure as 
 a means of checking, 20, 24. 
 
 in muscular sprains, 24. 
 
 in articular sprains, 24. 
 
 aspiration for, 79. 
 Ewen's plaster, 224. 
 
 Fatigue, to be avoided while prac- 
 tising movements and exer- 
 cises, 81. 
 Femur, internal and external con- 
 dyles of. 111. 
 Fibrinous loose bodies, 66. 
 Fibrolysin, 228. 
 
 Fixed apparatus, disadvantages of, 
 
 in treatment of sprains, 26, 28. 
 
 ' Floating patella ', as symptom in 
 
 sprain of knee, 113. 
 
 value of, 114. 
 
 Fomentations with anodine lotions 
 
 for relief of tension, 34. 
 ' Footballer's knee,' 116. 
 Forcible movements of stiff joints 
 under an anaesthetic, 216. 
 limitations of, 216. 
 special advantages of, 216. 
 contra-indications for, 217. 
 indications for, 217. 
 rules governing use of, 217-18. 
 Fracture-sprain, 10. 
 
 X-rays in diagnosis of, 8. 
 treatment of, 38. 
 causes of imperfect recovery, 38. 
 treatment of, compared with that 
 
 of simple sprain, 39. 
 of wrist-joint, 84-7. 
 of metacarpal bone of thumb, 96. 
 
 Gamgee-tissue, 28. 
 
 as application in elastic com- 
 pression, 23. 
 
 Gastrocnemius muscle, in case of 
 ossifying myositis, 62. 
 
 General injuries to muscles and 
 tendons, 169-86. 
 
INDEX 
 
 233 
 
 Genu- valgum or genu- varum, as 
 
 result of sprained knee, 55. 
 etiology of, 55. 
 Gluteal muscles, 54, 101. 
 Glycosuria as a complication of 
 
 sprains, 19. 
 Godlee, R. J., Professor, 163. 
 Gout as a complication of sprains, 
 
 30. 
 Gymnasium, exercises at, 81, 216, 
 
 220. 
 
 Hsematomata in sprains, 10. 
 as complication, 14, 30. 
 operation for large, 79. 
 Haemophilia as complication of 
 
 sprains, 28. 
 Haemorrhage, in articular and mus- 
 cular sprains, 9. 
 means of checking, 20. 
 Hamstring muscles, rupture of, 199. 
 usual sites of, 200. 
 causes, symptoms, prognosis, and 
 treatment of, 200. 
 Heat in treatment of sprains, 33. 
 Hernia of muscles, 84, 170. 
 adductor longus, 171. 
 rectus abdominis, 171. 
 rectus femoris, 171. 
 tensor vaginae femoris, 171. 
 tibialis anticus, 171. 
 Hip, contusions of, treatment of, 
 
 101. 
 Hip, sprains of, 100. 
 causes of, 100. 
 symptoms of, 100. 
 painful nature of, 100. 
 difficulty of diagnosis in, 101. 
 prognosis and treatment of, 100, 
 
 101. 
 osteo- arthritic changes in, 101. 
 wasting of muscles in, 101. 
 Hip- joint, ball-and-socket arrange- 
 ment of, 4. 
 Hot fomentations in treatment of 
 
 sprains, 34. 
 Hunter, John, 208, 209. 
 Hyaline cartilage, 94. 
 
 purposes of, in structure of joints, 
 2. 
 Hypertrophy of synovial fringes, 
 symptoms of, 168. 
 diagnosis of, 168. 
 operative treatment of, 168. 
 
 Iliacus muscle, 14. 
 Ilio-psoas muscle and tendon, rup- 
 ture of, 190. 
 causes, symptoms, and treatment 
 of, 190. 
 Immediate massage, 213. 
 Improper union of muscles and 
 tendons, as sequela of sprains, 
 41, 55. 
 Indications for massage, 213. 
 Individual injuries to muscles and 
 
 tendons, 187-209. 
 Inflammation in joints, etiology of, 
 
 32. 
 Infra-patella pad, 46. 
 Injuries, diagnosis and treatment 
 
 of, 1. 
 Inter-articular fibro-cartilage of 
 knee, 15, 111, 132. 
 surgical anatomy of. 111. 
 special attachments to, 112. 
 anatomical variations in, 113. 
 Inter-articular fibro-cartilage of 
 
 sterno-clavicular joint, 74. 
 Inter-muscular septa, overstretch- 
 ing and tearing of, in elbow - 
 sprain, 84. 
 Internal derangement of knee-joint, 
 124. 
 terms synonymous with, 124. 
 causation of, 124. 
 surgical pathology of, 124. 
 common site for laceration of 
 internal cartilage, 125. 
 Internal condyle of femur. 111. 
 Internal lateral ligament of knee, 
 110. 
 rupture of, 119. 
 causes of, 119. 
 
 usual sites of laceration in, 119. 
 symptoms of, 119. 
 diagnosis and treatment of, 121. 
 Internal semilunar cartilage, longi- 
 tudinal splitting of, 128. 
 anatomy of, 131. 
 more liable to injury than 
 external, factors concerned in, 
 132. 
 Iodine, liniment and tincture of, 
 222. 
 
 Johnson and Johnson's plaster, 196, 
 
 224. 
 Joint, cavity of, 3. 
 
234 
 
 INDEX 
 
 Joint, distension of, from injury or 
 
 disease, 3. 
 persistent pain in, 51. 
 Joints, adhesions within, 2. 
 total disablement of, 2. 
 capsule of, 2. 
 
 structure and function of, 2. 
 blood-vessels of, 3. 
 nervous supply of, physiological 
 
 relation of, 3. 
 stability and strength dependent 
 
 upon, 3. 
 inter-articular cartilages of, 5. 
 gliding movements as a source of 
 
 strength of, 5. 
 loose bodies in, 16, 65, 66, 72. 
 tension in, 32. 
 ' weak joint ',48. 
 ' wobbly joint ', 48. 
 causes of neuralgia in, 52. 
 crippled and deformed as sequela 
 
 to sprain, 53. 
 ' Jumper's (broad) sprain ', 169, 
 
 200. 
 
 Knee-joint, 4, 
 
 disorganization of, as a result of 
 
 enforced exercise, 16, 17. 
 treatment of sprain of by elastic 
 
 pressure, 22, 23. 
 open operation not to be lightly 
 
 considered, 34. 
 sprains in region of, 109. 
 surgical anatomy of, 109. 
 internal derangements of, 124: 
 pedunculated bodies in, 168. 
 Knee-joint, sprains of, 101, 109. 
 capsular ligament of, 109. 
 patellar ligament of, 110. 
 posterior ligament of, 110. 
 internal lateral ligament of, 
 
 110. 
 long external lateral ligament of, 
 
 110. 
 crucial ligaments of, 110. 
 quadriceps extensor tendon of 
 
 inter-articular fibro-cartilage of, 
 
 111. 
 coronary ligaments of, 113. 
 differential diagnosis of, 115. 
 usual site of pain in, 115. 
 after-effects of, 116. 
 treatment and prognosis of, 116. 
 Konig, Professor, 68. 
 
 ' Labourer's back ', 170. 
 Langton, J., Mr., 163. 
 Laparotomy, 157. 
 ' Lawn- tennis leg ', 183. 
 nature of injury, 203. 
 symptoms, diagnosis, prognosis, 
 and treatment of, 204, 205. 
 Leather straps for wrist, 223. 
 Leslie's plaster, 18. 
 Leucoplast, 18, 224. 
 Ligamenta alaria, 46, 155, 168. 
 photograph of specimen removed 
 
 by operation, 69. 
 conversion of, into fibrous bands, 
 71. 
 Ligamentum mucosum, 46, 155, 
 
 168. 
 Ligaments, inter-articular, 2. 
 ossification of, 3. 
 stretching and elongation of, from 
 
 distension of joint cavity, 3. 
 injury of, in elbow- joint, 82. 
 of sacro-iliac joints, 107. 
 capsular, of knee-joint, 109. 
 patellar, of knee, 110, 198, 202, 
 
 203. 
 posterior, of knee, 110. 
 internal lateral, of knee, 110, 115, 
 
 119. 
 long external lateral of knee, 110, 
 
 121. 
 crucial ligaments of knee. 111, 
 
 112, 131. 
 coronary of knee, 113. 
 external lateral of knee, 121. 
 Lindsey & Sons, Messrs., 150. 
 Liniments in use, 222. 
 Local applications in treatment of 
 sprains and injuries to joints, 
 222. 
 Local depletion and flushing in 
 
 treatment, 36. 
 Local heat a symptom of tension in 
 
 joints, 32. 
 Localized palsy and paresis as 
 
 sequelae, 57. 
 Long external lateral ligament of 
 
 knee, 110. 
 Longitudinal splitting of internal 
 
 semilunar cartilage, 128. 
 Loose bodies in joints, 16, 57, 65, 72. 
 classification of, 65, 66. 
 etiology of, 66, 68, 69, 72. 
 pedunculated loose bodies, 70. 
 
INDEX 
 
 235 
 
 Loose bodies in joints, developing 
 in ligamenta alaria, 71. 
 microscopical appearance of, 71. 
 commoner varieties of, 71. 
 symptoms and treatment of, 72. 
 preliminaries to operative treat- 
 ment of, 73. 
 Lower extremity, rupture of muscles 
 of, 190. 
 
 * Mallet-finger ', anatomy of, 97. 
 symptoms of, 97. 
 how caused, 97. 
 
 deformity in consequence of, 97. 
 photographs of, 98. 
 treatment of, 98-9. 
 author's operation for, 99-100. 
 Malleoli, 102, 105, 176. 
 Marsh, Howard, Professor, 175. 
 Massage, for reducing pain, 18. 
 uses of, as an assistant to elastic 
 
 pressure, 25. 
 supposed disadvantages of, 25. 
 when and how to apply, 26. 
 in treatment of fracture-sprain, 
 
 38, 40. 
 in treatment of sprains, 210. 
 physiology of, 210. 
 mechanical action of, 211. 
 limitations of, 212, 213. 
 indications and contra-indica- 
 
 tions of, 213. 
 immediate massage, 213. 
 Massage movements and exercises 
 in treatment of sprains and 
 bruises, 210. 
 Mead's plaster, 18. 
 Medical practitioner, treatment of 
 
 sprains by, 1. 
 Mercury, uses of, in constitutional 
 
 complications, 30. 
 Mesoblast, common ancestor of, 3. 
 structures in joints derived from, 3. 
 Metacarpal bone, Bennett's fracture 
 of, 96. 
 photographs of, 95. 
 linear fracture of metacarpal bone 
 of thumb, 96. 
 Metacarpo- phalangeal joints, injury 
 of, in sprains of thumb, 95, 96. 
 Metatarsal pain, causes of, 106. 
 description of, 106. 
 symptoms and treatment of, 106, 
 107. 
 
 Metatarso-phalangeal joints, 106. 
 Minor surgery, ' little things of, 6. 
 
 importance of, 6. 
 Movements and exercises, in treat- 
 ment of sprains and bruises,. 
 210-21. 
 against resistance, 220. 
 Mucin, 2. 
 
 Muscle sprain, 9. 168. 
 examples of, 170. 
 symptoms and treatment of, 170* 
 Muscle strain, 170. 
 Muscle- wasting, as result of treat- 
 ment by splints, 26. 
 as a serious complication of 
 
 sprains, 26. 
 as a result of lesions of nerves, 37.^ 
 as a sequela of sprains, 41. 
 caused by injury to nerve supply^ 
 
 43. 
 and from disuse, 43. 
 following immediately upon in- 
 jury, 43. 
 causes of, 43. 
 
 author's means of preventing, 
 218-220. 
 Muscles, atrophy of, acting on. 
 joints, 2, 43. 
 ossification of, 63. 
 regeneration of atrophied, 81, 
 hernia of, 84, 
 causes of, 170. 
 examples of, 171. 
 symptoms, diagnosis, and treat- 
 ment of, 172-3. 
 operation for suturing, 196. 
 of lower extremity, rupture of, 193. 
 of trunk, ruptures of, 187. 
 of calf, mode of strapping, 227. 
 of chest, mode of strapping, 225. 
 of thigh, mode of strapping, 226. 
 Muscles, injured, and in region of 
 injuries — 
 rectus abdominis, 31, 171, 188, 
 
 226. 
 psoas, 31. 
 iliacus, 31. 
 
 adductor longus, 43, 62, 63, 201. 
 deltoid, 43, 56, 77. 
 gluteal, 54, 101. 
 pectineus, 62. 
 sub-deltoid bursa, 77, 79. 
 intra-spinatus, 77. 
 supra-spinatus, 77. 
 
236 
 
 INDEX 
 
 Muscles, injured, and in region of 
 injuries — 
 
 sacro-lumbalis, 35, 170, 181, 190. 
 . proximal, 50. 
 
 rectus fern oris, 56, 193, 194. 
 
 quadratus extensor, 60, 199. 
 
 crureus, 60. 
 
 soleus, 61, 62. 
 
 gastrocnemius, 62. 
 
 supinator longus, 83. 
 , extensor carpi radiales longiores 
 
 et breviores, 84. 
 . popliteus, 122. 
 
 pronator radii teres, 169. 
 
 tensor vaginae femoris, 171. 
 
 tibialis anticus, 171. 
 
 the peronei, 174. 
 
 plantaris, 183, 203. 
 
 oblique, of abdomen, 188. 
 
 triceps, 190. 
 
 hamstring, 199, 200. 
 
 adductor magnus, 202. 
 Muscles and tendons, general in- 
 juries to, 170-86. 
 
 individual injuries to, 187-209. 
 Myositis ossificans as sequela, 60. 
 
 treatment of, 63-4. 
 
 Nation, wage-earning capacity of, 6. 
 Nerve, sciatic, injury to, 13. 
 Nerves, lesions of, as complication 
 of sprains, 35. 
 
 difficulty of early diagnosis of, 35. 
 
 importance of seeking for, 35. 
 
 numbness and tingling as symp- 
 toms of, 35. 
 
 symptoms due to tearing of, 35. 
 
 massage in treatment of, 36. 
 
 absolute and complete rest often 
 imperative, 36. 
 
 treatment of, ^6. 
 
 local neuritis as result of, 37. 
 
 static electricity in treatment of, 37. 
 
 blistering in treatment of, 37. 
 
 opiates contra-indicated in, 37. 
 
 wasting of muscles in, 37. 
 
 pain in, as result of pressure, 51. 
 
 circumflex, pressure upon cause 
 of pain in sprain of shoulder- 
 joint, 77. 
 Neuralgia, causes of, in painful 
 joints, 52. 
 
 treatment of, 53. 
 Neuritis, chronic atrophic, 12. 
 
 Neuritis, local treatment of, 37. 
 as a cause of persistent pain in 
 
 a joint, 51. 
 as complication of sprain of 
 shoulder- joint, 77. 
 Nutrition of joints, influenced by 
 alternate flushing and deple- 
 tion in treatment by elastic 
 pressure, 24. 
 
 Oblique muscles of abdomen, rup- 
 ture of, 188. 
 
 causes, symptoms, prognosis, and 
 treatment of, 188, 189. 
 Open operation, not to be lightly 
 considered, 34. 
 
 often only means of cure, 34. 
 Operation, for displaced semilunar 
 cartilage, author's method of, 
 153. 
 
 for exploratory arthrotomy, 34. 
 
 for large haematomata, 79. 
 
 for'droptop' or 'mallet-finger ',99. 
 
 for suturing muscles, 196. 
 
 for rupture of quadriceps extensor, 
 199. 
 
 for displacement of peroneal ten- 
 dons, 177. 
 
 for ruptured patellarligament,203. 
 Orbicular ligament, of elbow- joint, 
 
 82. 
 Ossifying myositis, 57. 
 
 usual situations of, 58. 
 
 etiology of, 58. 
 
 osteo-blasts in production of, 60. 
 
 structure of bone in, 60. 
 
 symptoms of, 63. 
 
 in quadratus extensor muscle, 60. 
 
 in crureus muscle, 60. 
 
 in soleus muscle, 61, 62. 
 
 in gastrocnemius muscle, 62 
 
 in deltoid muscle, 62. 
 
 in adductor longus muscle, 62. 
 
 in pectineus muscle, 62. 
 
 diagnosis of, important, 63. 
 
 preventive and curative treat- 
 ment of, 64. 
 Ossification of muscle, symptoms 
 of, 62, 63. 
 
 mistaken for sarcoma of thigh, 63. 
 Osteo-arthritiSjCrepitus occasionally 
 present in, 15. 
 
 as sequela, 16, 57, 64. 
 
 as result of injury, 64. 
 
INDEX 
 
 237 
 
 Osteo-arthritis, etiology and path- 
 ology of, 65. 
 treatment of, 65. 
 calcareous deposition a possible 
 forerunner of, 71. 
 Osteo-blasts, in production of ossify- 
 ing myositis, 60. 
 Osteo-chondritis dissecans, 68. 
 
 Pain, as a symptom of tension in 
 joints, 32. 
 persistent, in joints, 41, 51. 
 metatarsal, 106. 
 Painful and stiff joints, general 
 
 causes of, 42. 
 Palsy, localized, as sequela of 
 sprain, 57. 
 etiology of, 57. 
 treatment of, 58. 
 Papillae, liypertrophied, of synovial 
 membrane, in chronic synovitis, 
 70. See Villi. 
 Paralysis, local, as sequela of sprain, 
 
 56. 
 Paresis, local, as sequela of sprain, 
 
 56, 57. 
 Passive movements, comparison 
 with active, in treatment of 
 sprains, 27. 
 in simple sprain, 27, 214. 
 limitations of, 27. 
 mechanical action of, 27, 214. 
 in sprain-fracture, 38, 214. 
 contra-indications of, 214. 
 special uses, 214. 
 Patella, floating, 113. 
 Patellar ligament, rupture of, 198, 
 202. 
 symptoms, diagnosis, and treat- 
 ment of, 202, 203. 
 operative treatment of, 203. 
 Pectineus muscle, 62. 
 
 rupture of, 200. 
 Pectoral muscle, rupture of, 190. 
 Pectoralis major muscle, 191. 
 Pedunculated bodies in knee-joint, 
 
 168. 
 Periosteum, injury to, in ossifying 
 
 myositis, 58, 60, 61, 62. 
 Peroneal tendons, displacement of, 
 symptoms and treatment of, 
 177. 
 Persistent pain in joints, 41, 51. 
 Physiology of massage, 210. 
 
 Plantaris muscle, rupture of, 183. 
 Plasters, Mead's, 18. 
 Leslie's, 18. 
 Seabury's, 18. 
 
 Johnson and Johnson's, 196, 224. 
 various, 224. 
 Poirier, Professor, 133. 
 Popliteus muscle, 122. 
 Popliteus tendon, 132. 
 Posterior crucial ligament of knee, 
 
 attachments of, 131. 
 Posterior ligament of knee, 1 10. 
 Poupart's ligament, 190, 201. 
 Preventible sequelae of sprains, 41. 
 
 enumeration of, 41. 
 Prevention of muscle-wasting by 
 gentle, active, muscular exer- 
 cises and training, 218. 
 Prognosis in sprains, importance of, 
 
 16. 
 Pronator radii teres muscle, 169. 
 Proximal muscles of a joint, atrophy 
 
 in, 50. 
 Psoas muscle, 14, 35. 
 ' Pulled elbow ', symptoms of, 82. 
 injury of wrist in, 83. 
 diagnosis, treatment, and prog- 
 nosis of, 83. 
 
 Quadriceps extensor muscle of thighs 
 60, 183. 
 operation for rupture of, 199. 
 Quadriceps extensor tendon, rupture 
 of, 198. 
 diagnosis and treatment of, 198, 
 
 199. 
 operation for treatment of, 199. 
 
 Radcliffe Infirmary, 164. 
 
 Radiant heat in treatment of sprains, 
 
 33, 228. 
 Radiocarpal epiphysis, 85. 
 Radiographer, 89. 
 Radiography, 88, 93. 
 Radioscopy, 82. 
 Range of movement in stiff joints, 
 
 217. 
 Rawling, L. B., :Mr., 135. 
 Rectus abdominis muscle, 31, 171. 
 rupture of, 188. 
 causes, symptoms, and treatment 
 of, 188. 
 method of strapping, 226. 
 Rectus femoris muscle, 56. 
 rupture of, 194. 
 
238 
 
 INDEX 
 
 Rectus femoris muscle, rupture of, 
 symptoms and treatment of, 
 194-6. 
 
 plaster strapping for, 196, 197. 
 
 Recurrent or relapsing displacement 
 
 of semilunar cartilage, 137. 
 
 palliative treatment of, 149. 
 
 operative treatment of, indica- 
 tions for, 150. 
 
 preliminaries to operation, 152. 
 
 author's method for removing, 
 153. 
 
 illustrations of, 154-6. 
 
 after-treatment of, 162. 
 Recurring and relapsing synovitis, 
 44, 70. 
 
 arthrotomy for digital explora- 
 tion in, 34. 
 
 appearance of synovial membrane 
 in, 46. 
 
 appearance of naked-eye and 
 microscopic, 46. 
 
 nature of synovial secretion in 
 cases of, 46. 
 
 method of operation for, 46. 
 
 relaxed state of ligaments in cases 
 of, 50. 
 
 temperature charts in, 116. 
 Relapsing sprains, often dependent 
 upon health of individual, 28. 
 Rest, in treatment of sprains, 41-2. 
 Restoration of mobility in injured 
 joints, primary object in treat- 
 ment, 26. 
 Rheumatism as complication of 
 sprains, 29. 
 
 treatment of, 30. 
 
 * Rice bodies ' in joints as sequela of 
 
 sprain, 66, 71. 
 
 * Rider's sprain ', 43, 168, 183, 201. 
 
 Rigid splints, uses of, contra-in- 
 dicated in treatment of sprains, 
 26. 
 
 Rule-of-thumb methods, disadvan- 
 tages of, 1, 6, 7. 
 Rupture of muscles and tendons, 
 causes of, 182-3. 
 
 pathology of, 182. 
 
 clinical symptoms of, 183. 
 
 treatment of, 183-4. 
 
 athletic exercises in relation to, 
 184. 
 
 circumstances which influence 
 tendency to, 185-6. 
 
 Rupture of muscles and tendons — 
 influenced by season of year, 185. 
 
 by temperature of air, 185. 
 
 by want of training, 186. 
 
 by age of individual, 186. 
 
 by kind of game, 186. 
 of the body, 188. 
 of oblique muscles of abdomen, 
 
 188. 
 of rectus abdominis, 188, 226. 
 of upper extremity, 190. 
 of ilio-psoas, 190. 
 of sacro-lumbalis, 190. 
 of lower extremity, 193. 
 of rectus femoris, 193. 
 of tendons of forearm, 193. 
 of quadratus extensor, 198. 
 of hamstrings, 199. 
 of adductor longus, 201. 
 of adductor magnus, 202. 
 of patellar ligament, 202. 
 of plantaris, 203. 
 of tendo-Achillis, 206. 
 
 Sacro-coccygeal sprain, causes of, 
 107. 
 symptoms of, 107. 
 differential diagnosis of, 108. 
 treatment and prognosis of, 107-8. 
 coccygodynia a symptom in, 108. 
 Sacro-iliac ligaments, 107. 
 Sacro-lumbalis muscle, 35, 170, 
 181. 
 dislocation and rupture of, 190. 
 symptoms and treatment of, 
 190. 
 Sankey, R. H., Mr., 89. 
 Scaphoid bone, cases illustrating 
 fracture of, 88-9, 90-1. 
 clinical symptoms of, 90-1. 
 Mr. Elliot Stanford's case, 91. 
 treatment of, 92, 94. 
 prognosis of, 94. 
 Sciatic nerve, injury to, 13. 
 Scott's dressing, 223. 
 Seabury's plaster, 196, 198, 224. 
 Semilunar cartilages of knee, cal- 
 careous deposition in detached, 
 71. 
 longitudinal splitting of internal, 
 
 128. 
 internal more liable to injury than 
 external, 131. 
 factors concerned in, 131-2. 
 
INDEX 
 
 239 
 
 Semilunar cartilages of knee, changes 
 observable in cartilages that 
 have become detached or torn, 
 135. 
 
 drainage for, 157. 
 
 author's method of operation for 
 displacement of, 153. 
 
 apparatus for preventing displace- 
 ment of, 223. 
 
 See Displaced semilunar carti- 
 
 Semi-membranosus muscle, rupture 
 
 of, 200. 
 Semi-tendinosus muscle, rupture of, 
 
 200. 
 Separation of body of an internal 
 semilunar cartilage from deep 
 fibres of internal lateral liga- 
 ment of joint, 122. 
 symptoms and results of, 122. 
 Separation of epiphysis for anterior 
 inferior spinous process of 
 ilium, 194. 
 Sequelae of sprains, 41. 
 preventable, 41. 
 unavoidable, 41, 56-7. 
 Serous effusion in joints, 10. 
 Simple sprain, 9, 17. 
 
 passive movements in, 27, 214. 
 treatment of, compared with that 
 of fracture-sprain, 39. 
 Simple strains, 18. 
 Shoulder-joint, integrity of, depen- 
 dent upon strength of its liga- 
 ments, &c., 4. 
 weakness of, 4. 
 sprains of, 76. 
 surgical anatomy of, 76. 
 symptoms of, 77. 
 swelling often considerable in, 
 
 77. 
 diagnosis of, 78. 
 liability to atrophy of muscles 
 in, 77. 
 causes of pain in, 77, 79. 
 treatment of, 78-9. 
 aspiration in treatment of, 79. 
 complications of, 79. 
 movements in, importance of 
 early, 79. 
 treatment of, 80. 
 permanent ill-effects of, 80. 
 ' Slipped cartilage ', 124. 
 subluxation of, 124. 
 
 Soleus muscle, ossifying myositis in, 
 
 61-2. 
 Special sprains — 
 
 shoulder- joint, 76. 
 
 wrist, 84. 
 
 thumb, 94. 
 
 hip- joint, 100. 
 
 ankle-joint, 101. 
 
 knee-joint, 101, 113. 
 Splenius capitus muscle, 179. 
 Splints, prolonged and constant use 
 of harmful, 42. 
 
 uses of strictly limited, 42. 
 Sprain-dislocation, 12 
 ' Sprained elbow ',81. 
 
 causation of, 83. 
 
 exercises productive of, 84. 
 
 symptoms of, 84. 
 Sprain-fracture, 1, 10, 16. 
 
 pathological significance of, 8. 
 
 passive movements in, 38, 214. 
 
 causes of stiffness in, 40. 
 
 ankylosis as sequela of, 41, 56. 
 Sprain with fracture, 10, 214. 
 Sprain, with immediate swelling, 9, 
 19. 
 
 of external lateral ligament of 
 knee, 14, 121. 
 
 of elbow- joint, 81, 83. 
 
 of the body, 107. 
 
 sacro-coccygeal, 107. 
 
 in region of knee-joint, 108. 
 Sprains, anatomical conditions un- 
 derlying, 1. 
 
 treatment of, 1. 
 
 pathological conditions of, 1. 
 
 general considerations of, 6. 
 
 definition of, 7. 
 
 classical conception of, 8. 
 
 articular, 8. 
 
 of muscle, 9. 
 
 complicated with injuries to bone, 
 10. 
 
 hsematomata in, 10. 
 
 complicated with injury to nerve, 
 12, 35. 
 numbness a symptom of, 12, 
 
 anaesthetics in treatment of, 14, 
 
 diagnosis of, 14. 
 
 complicated with hsematomata, 
 14. 
 
 crepitus as a symptom of, 15. 
 
 warm applications in treatment 
 of, 19, 78. 
 
240 
 
 INDEX 
 
 Sprains, cold in treatment of, 19. 
 
 elastic pressure in treatment of, 
 20, 22. 
 
 treatment of deferred swelling in, 
 27. 
 
 with fracture, treatment of, 38. 
 
 rest in treatment of, 41. 
 
 ' Rider's sprain ', 43. 
 
 evaporating lotions in treatment 
 of, 50. 
 
 treatment of improper union of 
 muscles and tendons as sequela 
 of, 55. 
 
 paresis and paralysis as sequelae 
 of, 56. 
 
 unavoidable sequelae of, 56-7. 
 
 of acromio-clavicular joint, 75. 
 
 of shoulder- joint, 76. 
 
 of thumb, 94. 
 
 of the hip, 100. 
 
 of tarso -metatarsal joint of great 
 toe, 107. 
 
 of the knee, 109-16. 
 
 of internal lateral ligament of 
 knee, 119-20. 
 
 massage and movements in treat- 
 ment of, 210. 
 Spring-truss for knee, 224. 
 ' Sprinter's thigh ', 183. 
 Stanford, Mr. Elliot, fracture of sca- 
 phoid bone by, 91. 
 
 description of, 91-3. 
 Static electricity in treatment of 
 
 nerve lesions, 37. 
 Sterno- clavicular joint, sprain of, 
 74. 
 
 anatomy of injury, 74. 
 
 S3naaptoms and treatment of, 74. 
 Stiffness in joints, 41. 
 
 causes of, 42. 
 
 range of movement in stiff- joints, 
 217. 
 Strain, anatomical conditions under- 
 lying, 1. 
 
 the simplest form of sprain, 9. 
 
 treatment of simple, 18. 
 
 of internal lateral ligament of 
 knee, 119. 
 Strapping, for strains, 18. 
 
 of injured muscles, advantages of, 
 197, 198. 
 
 for muscles of chest, rectus abdo- 
 minis, muscles of thigh, muscles 
 of calf, 225-7. 
 
 Strapping, for knee, ankle, foot, and 
 
 shoulder, 227. 
 Strata, fascial and inter-muscular, 3. 
 Styloid processes of radius, fracture 
 
 of, 85-6. 
 Sub-deltoid bursa muscle, 77. 
 haemorrhage into, in sprains of 
 shoulder- joint, 77. 
 Subluxation, 124. 
 
 of head of radius, 82. 
 Surgical anatomy, general, of joints, 
 2-4. 
 of knee-joint, 108. 
 of inter-articular fibro-cartilage 
 of knee. 111. 
 Synovia, function of, 2. 
 Synovial cavity, stomata in con- 
 nexion with, 3. 
 Synovial fringes, 46, 68, 168. 
 Sjrnovial membrane, folding of, 2. 
 villi or papillae of, 2, 3. 
 appearance of, in relapsing syno- 
 vitis, 46. 
 Synovitis, chronic, hypertrophy of 
 papillae in, 70. 
 formation of loose bodies in, 70. 
 drainage for, 49. 
 recurring and relapsing, 44. 
 general relaxation of ligaments as 
 
 result of, 44. 
 treatment of, 44. 
 presence of adhesions as a cause 
 
 of, 44. 
 means of preventing, 44. 
 use of anaesthetics in, 45. 
 forcible movements in treatment 
 
 of, 45. 
 exploratory arthrotomy in treat- 
 ment of, 45. 
 acute traumatic of knee, 116. 
 
 Tarsal joint, 4. 
 
 Tarso-metatarsal joint of great toe, 
 107. 
 
 Temperature, high degrees of, appli- 
 cation in treatment of sprains, 
 228. 
 
 Temperature charts, in operation 
 for displaced semilunar carti- 
 lage, 158-61. 
 for exploratory arthrotomy, 47. 
 
 Temporo-maxillary joint, 12. 
 inter-articular cartilage of, 12. 
 
 Tendo-Achillis, rupture of, 206. 
 
INDEX 
 
 241 
 
 Tendo-Achillis, rupture of, S5mip- 
 toms, diagnosis, and treatment 
 of, 206-9. 
 ossification in, 208. 
 Tendons, treatment of improper 
 union of, as sequela of sprains, 
 55. 
 quadriceps extensor, 110, 113. 
 popliteus, 113, 132. 
 displacement or dislocationof , 173. 
 examples of, 173. 
 the peroneal, 174, 177. 
 long of biceps, 178. 
 small, at back of neck, 178, 181. 
 rupture of, causes of, 182-3. 
 of forearm, rupture of, 193. 
 ilio-psoas, rupture of, 190. 
 ' Tennis elbow ', 169. 
 Tension in joints, local treatment 
 of, 32. 
 local heat as symptom of, 32. 
 aspiration in treatment of, 33. 
 uses of elastic pressure in, 33. 
 Tensor vaginae femoris muscle, 171. 
 Thumb, sprains of, 94. 
 causes of, 95. 
 
 carpo-metacarpal joints of, in- 
 juries to, 95. 
 metacarpo-phalangeal joints of, 
 
 injuries of, 95. 
 symptoms of, 95. 
 differential diagnosis of, 96. 
 treatment of simple sprain of, 97. 
 prognosis of, 97. 
 sprain-fracture of, 97. 
 treatment of, 97. 
 Tibialis anticus muscle, 171. 
 Tincture of iodine, 222. 
 Traumatic hydrops, etiology of, 116. 
 Treatment of recurring and relaps- 
 ing displacement of semilunar 
 cartilages, 149-50. 
 Treatment of sprains, 17. 
 Triceps muscles, rupture of, 190. 
 Tuberculosis as sequela and com- 
 plication of sprain, 31. 
 
 Tumour as sequela and complica- 
 tion of sprain, 16. 
 Tunnicliffe, Dr., 211. 
 
 Unavoidable sequelas of sprains, 
 56-7. 
 classification of, 56-7. 
 Unregistered practitioners, 7. 
 Upper extremity, rupture of muscles 
 of, 190. 
 causes, symptoms, and treatment 
 of, 190. 
 
 Vasogen-iodine, 30, 222. 
 Villi of synovial membranes, dis- 
 eased conditions of, 2. 
 development of cartilage or bone 
 
 from, 3. 
 hypertrophy in chronic S3movitis, 
 69. 
 
 Warm applications in treatment of 
 
 sprains, 19, 78. 
 'Weakjoint', 41, 48. 
 Whitelocke, R. H. Anglin, Mr., 
 
 139, 194. 
 Wicket-keepers, injuries to fingers 
 
 of, 55. 
 'Wobblyjoint', 41, 48. 
 local treatment of, 51. 
 Workmen's Compensation Act, 6, 
 
 17. 
 Wrist, 4 
 
 leather straps for, 223. 
 Wrist- joint, sprain of, in 'pulled 
 elbow', 83. 
 simple sprain of, 84. 
 etiology of, 85. 
 symptoms of, 85. 
 differential diagnosis of, 85. 
 treatment of, 87. 
 swelling in sprain of, 86. 
 
 X-rays as an aid to diagnosis, 8, 16 
 40, 55, 60, 63, 82, 88, 97, 98, 
 103, 202. 
 
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