UC-NRLF 
 
 $B 171 552 
 
MASSAGE IN 
 
 EECENT FKACTUKES 
 
 SPBAINS AND THEIK CONSEQUENCES 
 
 KIGIDITY OF THE SPINE 
 
 AND THE 
 
 MANAGEMENT OF STIFF JOINTS 
 GENEKALLY 
 
LECTUKES AND ESSAYS 
 
 BY 
 
 SIR WILLIAM H. BENNETT. 
 
 ON THE USE OF MASSAGE AND EARLY MOVE- 
 MENTS IN KECENT FEACTUEES AXD OTHER 
 
 COMMON STJRGICA.L INJURIES. SPEAINS AND 
 
 THEIE CONSEQUENCES, EIGIDITY OF THE 
 SPINE, AND THE MANAGEMENT OF STIFF JOINTS. 
 
 8vo. 6s. 
 
 EECUEEENT EFFUSION INTO THE KNEE-JOINT 
 AFTEE INJUEY, with especial reference to IN- 
 TEENAL DEEANGEMENT, commonly called 
 SLIPPED CAETILAGE : an Analysis of 750 cases. 
 8vo. 3s. 6d. 
 
 THE PEESENT POSITION OF THE TREATMENT OF 
 
 SIMPLE FRACTURES. 8vo. 2*. &d. 
 
 VAEIX, with especial reference to THROMBOSIS. 8vo. 3s. Gd. 
 VAEICOSE VEINS OF THE LOWEE EXTREMITIES. 
 
 8vo. 6s. 
 
 VAEICOCELE. A Practical Treatise. 8vo. 5s. 
 ABDOMINAL HEENIA, including the Eadical Care. 8vo. 
 
 8s. 6d. 
 
 LONGMANS, GEEEN, & CO., 39 Paternoster Eow, London 
 New York, Bombay, and Calcutta. 
 
LECTURES 
 
 ON 
 
 THE USE OF MASSAGE 
 
 AND 
 
 EARLY MOVEMENTS IN RECENT FRACTURES 
 
 AND OTHER COMMON SURGICAL INJURIES 
 
 SPRAINS AND THEIE CONSEQUENCES 
 KMDITY OF THE SPINE 
 
 AND THE 
 
 MANAGEMENT OF STIFF JOINTS 
 
 GENEKALLY 
 
 BY 
 
 SIB WILLIAM H. BENNETT, KC.V.O., F.E.C.S. 
 
 CONSULTING SURGEON TO ST. GEORGE'S HOSPITAL 
 
 AND TO THE HOSPITAL OF ST. JOHN AND ST. ELIZABETH 
 
 SENIOR SURGEON TO THE SEAMEN'S HOSPITAL, GREENWICH, ETC. 
 
 FIFTH EDITION 
 
 WfTH V3 ILLUSTRATION 
 
 LONGMANS, GEEEN, AND CO. 
 
 39 PATERNOSTER ROW, LONDON 
 
 NEW YORK, BOMBAY, AND CALCUTTA 
 
 1910 
 
 All rights reserved 
 
BIBLIOGRAPHICAL NOTE 
 
 First printed October, 1900 
 
 Second Edition April, 1902 
 
 Third Edition June, 1903 
 
 Fourth Edition April, 1909 
 
 Fifth Edition June, 1910 
 
PREFACE 
 
 TO 
 
 THE FOUKTH EDITION 
 
 IN the present Edition the Lectures on Massage and 
 Early Movements in Fractures have been revised. 
 Two Lectures dealing with Sprains and their conse- 
 quences and Rigidity of the Spine replace that on 
 Derangements of the Knee-joint which has been 
 omitted. The illustrations have been increased in 
 number. 
 
 CHESTERFIELD STREET, MAYFAIR, W : 
 April, 1909. 
 
 387678 
 
CONTENTS 
 
 PAGE 
 
 INTRODUCTION . . 1 
 
 MASSAGE 2 
 
 EARLY PASSIVE MOVEMENT .5 
 
 VOLUNTARY MOVEMENT 7 
 
 POSTURE 8 
 
 CONCLUSIONS 10 
 
 LECTURE I 
 
 THE USE OF MASSAGE AND EARLY MOVEMENTS IN 
 EECENT FRACTURES AND OTHER COMMON INJURIES : 
 
 OBJECTS OF THE METHOD ....... 14 
 
 MODE OF APPLICATION . . . . . . . . 19 
 
 IN FRACTURE OF THE LEG ....... 20 
 
 IN POTT'S FRACTURE ........ 28 
 
 IN FRACTURE OF THE NECK OF THE FEMUR ... 30 
 
 IN COLLES'S FRACTURE . . . . . . ... 32 
 
 IN FRACTURES ABOUT THE SHOULDER-JOINT . . . .35 
 
 OBJECTIONS TO THE METHOD , 40 
 
 LECTURE II 
 
 THE USE OF MASSAGE AND EARLY MOVEMENTS IN 
 RECENT FRACTURES AND OTHER COMMON INJURIES 
 (continued) : 
 
 IN FRACTURE OF THE PATELLA 43 
 
 IN FRACTURE OF THE OLECRANON 47 
 
 IN DISLOCATIONS 51 
 
 IN SPRAINS, WRENCHES, AND BRUISES . . . . . 58 
 THE AMBULATORY TREATMENT ...... 64 
 
viii CONTENTS 
 
 LECTUEE III 
 
 PAGE 
 
 SPRAINS AND THEIR CONSEQUENCES: 
 
 DEFINITION AND CLASSIFICATION OF SPRAINS ... 67 
 DIAGNOSIS AND TREATMENT 69 
 
 Simple Sprains. 
 
 Sprains without Swelling. 
 
 Sprains with Immediate Swelling. 
 
 Tension in Joints after Sprain. 
 
 Sprains with Fracture. 
 
 Sprains with Gross Nerve Injury. 
 
 REMOTE CONSEQUENCES OF SPRAINS 80 
 
 PREVENTABLE CONSEQUENCES . . . . . . . . 81 
 
 UNAVOIDABLE CONSEQUENCES OF SPRAINS . . . .86 
 
 LECTURE 1Y 
 
 STIFFNESS OF THE SPINE: 
 
 CAUSES OF STIFFNESS 91 
 
 DISTRIBUTION AND CHARACTER 92 
 
 PERSISTENT STIFFNESS 93 
 
 THE STAMMERING SPINE 97 
 
 CASES IN ILLUSTRATION 100 
 
 THE STAMMERING SPINAL JERK 102 
 
 INTERMITTENT OR RELAPSING STIFFNESS .... 103 
 
 REFLEX IRRITATION AS A CAUSE OF INTERMITTENT RIGIDITY 107 
 
 CALCULI AS CAUSATIVE FACTORS 109 
 
 TEMPORARY OR TRANSIENT RIGIDITY Ill 
 
 LECTURE V 
 
 THE RATIONAL TREATMENT OF STIFF JOINTS BY 
 MANIPULATION : 
 
 GENERAL CONSIDERATIONS ..... . 113 
 
 METHOD OF EXAMINATION OF STIFF JOINTS . . . 115 
 POINTS FOR CONSIDERATION IN DECIDING UPON THE PRO- 
 
 PRIETY OF THE BREAKING DOWN OF A STIFF JOINT . .118 
 
LIST OF ILLUSTRATIONS IX 
 
 ^ 
 
 PAGE 
 
 SUMMARY OF CONDITIONS IN FAVOUR OF AND AGAINST THE 
 ADOPTION OF THE EADICAL TREATMENT .... 125 
 
 POINTS RELATING TO THE DETAILS OF FORCIBLE MANIPULA- 
 TION OF JOINTS . 127 
 
 TREATMENT SUBSEQUENT TO BREAKING DOWN OF STIFF 
 JOINTS . . 130 
 
 THE HYPER^EMIC TREATMENT . 131 
 
 FIBRO-LYSIN IN STIFF JOINTS 134 
 
 LIST OF ILLUSTRATIONS 
 
 IN THE TEXT 
 
 FIGS. PAGE 
 
 1-6. ILLUSTRATING METHOD OF USING MASSAGE IN 
 
 RECENT FRACTURE 18-29 
 
 7. RESULT OF THE METHOD IN POTT'S FRACTURE . 31 
 
 8. RESULT OF THE METHOD IN COLLES'S FRACTURE . 34 
 
 9. RESULT OF THE METHOD IN FRACTURE THROUGH 
 
 CONDYLES OF FEMUR .39 
 
 10. SKIAGRAM OF DIFFICULT FRACTURE OF LEG 
 
 TREATED BY MASSAGE, &c 42 
 
 11. RESULT OF THE METHOD IN FRACTURE OF PATELLA 48 
 
 12. DIAGRAM SHOWING MECHANISM OF ANGULAR 
 
 DEFORMITY AFTER SUPPOSED SPRAIN OF A 
 FINGER .84 
 
 HALF-TONE PLATES 
 
 PLATE 
 
 I. X-RAY PHOTOGRAPH OF AN ORDINARY 
 FRACTURE OF THE TIBIA AND FIBULA 
 TREATED BY MASSAGE, &c. ... To face p. 30 
 
Beticeen 
 pp. 36 and 37 
 
 x LIST OF ILLUSTRATIONS 
 
 f 
 
 PLATE 
 
 II. X-RAY PHOTOGRAPH OF FRACTURE OF NECK 
 OF HUMERUS WHICH RECOVERED WITH- 
 OUT TREATMENT 
 
 III. PHOTOGRAPHS SHOWING FINAL CONDITION 
 
 FOLLOWING UPON THE INJURY SHOWN 
 IN PLATE II 
 
 IV. PHOTOGRAPHS SHOWING THE RESULT OF 
 
 THE TREATMENT OF A FRACTURE IN- 
 VOLVING THE ELBOW-JOINT BY MASSAGE 
 AND MOVEMENTS To face p. 38 
 
 V. ERNST'S INSTRUMENT FOR AMBULATORY 
 TREATMENT IN SLOW OR DELAYED UNION 
 AFTER FRACTURE OF THE THIGH . ,,64 
 
 VI. X-RAY PHOTOGRAPHS SHOWING UNSUS- 
 PECTED FRACTURES IN 'SPRAINS' OF 
 FINGERS ,,70 
 
 VII. X-RAY PHOTOGRAPHS OF UNSUSPECTED 
 FRACTURES IN ' MOTOR-SPRAINS ' OF 
 WRIST . ,,78 
 
 VIII. X-RAY PHOTOGRAPH OF AN IMPACTED 
 FRACTURE OF THE MALLEOLAR END OF 
 THE FIBULA ,,80 
 
 IX. X-RAY PHOTOGRAPH OF TRAUMATIC MYOS- 
 ITIS OSSIFICANS OF QUADRUCEPS EX- 
 TENSOR FEMORIS FOLLOWING UPON 
 SPRAIN ,,88 
 
 X. OSSIFIC MASSES ABOUT THE ELBOW AFTER 
 
 SPRAIN ,,88 
 
 XI. X-RAY PHOTOGRAPH OF A CASE OF BONY 
 ANKYLOSIS OF KNEE-JOINT BEFORE AND 
 AFTER ' BONE-SETTING ' 124 
 
MASSAGE AND MOVEMENTS 
 IN FRACTURES 
 
 INTRODUCTION 
 
 THE use of massage and early movements in recent 
 fractures, originally introduced by Lucas Cham- 
 pioniere, was first adopted and advocated in this 
 country by the present writer. In spite of the 
 coolness and, in some quarters, the scepticism with 
 which the treatment was at first received, there is no 
 doubt that the method has been steadily growing 
 in favour, and that it is now used either in its entirety 
 or with some modification by all rational surgeons. 
 The writer when first advocating the method was 
 frequently regarded as an enthusiast an entire 
 misapprehension. The sole object of his support of 
 the treatment was to obtain for it a fair trial with a 
 view to bringing about a more reasonable attitude 
 in the management of fractures than had previously 
 been adopted by surgeons generally. The method was 
 never advocated to the exclusion of the use of splints 
 or of operations in the treatment of recent fractures, 
 
2 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 but it was strongly urged that a fair consideration 
 should be afforded to a plan of treatment which, 
 if used discreetly as an adjunct to the ordinary 
 methods, modified as circumstances may demand, 
 was believed to be sound in theory and advantageous 
 in practice. This belief has, it can hardly be denied, 
 been justified by subsequent experience. The method 
 consists merely of the application of common-sense 
 principles in the treatment of these injuries. Indeed, 
 it cannot but excite surprise in the mind of any 
 intelligent person that the stiffness, pain, and other 
 disadvantages which so constantly follow the treat- 
 ment of fractures upon classical lines should have been 
 countenanced for so many years when they can, in 
 the majority of cases, be entirely obviated by a treat- 
 ment so simple as that described in the following 
 lectures. 
 
 MASSAGE. 
 
 The advantages derivable from shampooing and 
 manipulations in sprains, wrenches, and similar 
 injuries have been recognised for centuries, especially 
 as shown in the rapid removal of extra vasated blood, 
 the cure of cedema, the prevention of stiffness, and 
 the checking of muscle waste the identical complica- 
 tions which are prone to occur in fractures : a frac- 
 ture being nothing more than an exaggerated form of 
 sprain, the bone, in addition to the soft parts, having 
 
INTRODUCTION 3 
 
 been torn. It is presumed that no intelligent surgeon 
 who has had any practical experience would in these 
 days hesitate to use massage and movements in a case 
 of sprain or wrench, however severe, if the bone were 
 intact and the skin sound. The sole reason for avoid- 
 ing the application of these common-sense methods 
 in fractures seems to be the general belief that any 
 plan of treatment which would entail movement, 
 however slight, between the fragments, must be in- 
 imical to union and therefore unsound, if not actually 
 dangerous, in practice. It is, however, quite certain 
 that the very slight amount of movement entailed 
 by this method, if properly applied, not only has 
 no tendency to prevent union, but, on the contrary, 
 may sometimes tend to promote union by the in- 
 crease of callus so produced. It would be easy to 
 give instances in support of this contention. The 
 perfect manner in which union occurs in fracture of 
 the ribs, or the excellent union which often follows 
 upon fractures in the lower animals, notably the dog, 
 in which immobility is generally quite out of the 
 question, may be taken as examples ; on the other 
 hand, the remarkable frequency of non-union in frac- 
 tures of the skull, specimens of which may be found 
 in every museum, in which of necessity there has 
 been absolute immobility, should be noted. It must 
 not be inferred from what has just been said that 
 the writer advocates intentional movement of the 
 
 B 2 
 
4 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 fragments in recent fracture ; these remarks are 
 simply intended to emphasise the fact that the amount 
 of movement, if any, which occurs in the proper 
 application of this treatment is not sufficient to inter- 
 fere in any way with union, and need not, therefore, 
 stand in the way of the application of the common- 
 sense principles which apply, as a matter of course, 
 in ordinary sprains. 
 
 In any case of recent simple fracture, unless the 
 local condition of the skin from blistering or other 
 causes is contra-indicative, massage cannot be com- 
 menced too soon with a view to the relief of pain and 
 the prevention of spasm. The soothing effect upon 
 irritable muscles in the majority of cases is most 
 remarkable, in some instances rendering an apparently 
 unmanageable fracture quite amenable to ordinary 
 methods of reduction, which could not otherwise be 
 effected without operation a result the value of 
 which in some subjects can hardly be over-estimated. 
 The ease with which a difficult fracture can be 
 manipulated after it has been subjected to gentle, 
 smooth rubbing is often a revelation to those who 
 have had no experience in the matter. 
 
 Massage is, moreover, a useful precursor of 
 truly effectual voluntary movement, and it is an 
 integral factor in the production of the fullest benefit 
 derivable from passive movement, since the latter, 
 although it prevents adhesions, does not prevent 
 
INTRODUCTION 5 
 
 muscle waste to any great degree, a defect which is 
 supplied by massage. 
 
 EARLY PASSIVE MOVEMENT. 
 
 The object of early passive movement in recent 
 fractures is the very simple one of preventing adhe- 
 sions, as opposed to the results of the older methods of 
 absolute fixation of the limb, which of necessity leads 
 to some matting together of the parts about the frac- 
 ture, which, after union has taken place, frequently 
 requires for its cure either prolonged passive move- 
 ments or forcible breaking down under an anaesthetic ; 
 in any event, whatever treatment is adopted for the 
 rectification of the stiffness due to adhesions resulting 
 from long-continued fixation, the disability of the 
 patient is prolonged beyond all reasonable limits 
 and in some cases becomes permanent. There is 
 no doubt that in the many cases of fracture in 
 which permanent disability follows upon faulty posi- 
 tion of the fragments, the major part, and some- 
 times, indeed, all, of the disability is dependent upon 
 adhesions of the parts around the fracture and not 
 upon the bony deformity, unless this is great or 
 of the rotatory kind. In any case of fracture after 
 the fragments have been placed in accurate position 
 passive movements should be commenced at once. In 
 a fracture of the leg, for example, gentle movements 
 of the toes may be made immediately with a view to 
 
6 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 making some to-and-fro motion of the muscles about 
 the fracture (this is the so-called ' internal massage ') ; 
 in fact, from the very beginning of a case treated on 
 the lines under consideration the great object is to 
 keep the muscles around the fracture continually on 
 the move, which can be accomplished without any 
 harmful movement of the bone fragments. Not only 
 are adhesions thus prevented, but the circulation of 
 the limb is stimulated and rapid union promoted. 
 The earliest movements can be effected without the 
 removal of splints, but in every case, as soon as the 
 state of the fracture permits (i.e. from the third or 
 fourth day onward), the splints should be loosened 
 for gentle massage, by which the passive movement is 
 not only rendered more easy, but also more effectual. 
 
 The main points in making passive movement in 
 fractures which should be borne especially in mind 
 are the following : (1) Steady fixation of the fracture 
 itself should be insured, either by the grasp of the 
 hand or by appropriate splints or apparatus. (2) All 
 movements must be gently but deliberately made ; 
 the grasp of the parts by the manipulator's hand must 
 be firm and unhesitating, although gentle in this 
 way a sense of certainty and confidence is imparted 
 which generally removes any inclination to resistance 
 on the part of the muscles. 
 
 If, however, as sometimes happens, there should 
 arise between the hand of the manipulator and the 
 
INTRODUCTION 7 
 
 muscles of the patient some involuntary antagonism 
 (nearly always due to faulty handling of the parts), it 
 can as a rule be obviated by practising the movements 
 first on the sound limb, in order to give the muscles on 
 the damaged side some idea of what is expected of 
 them. The useful effect of this simple manoeuvre is 
 well demonstrated in cases in which a normal joint 
 has been kept still for some time in splints e.g. the 
 knee-joint in a case of fracture of the upper end of 
 the leg treated by plaster of Paris. Upon the removal 
 of the splint, if the patient be told to bend the joint 
 he will generally at first be unable to do so, but 
 in such cases, unless adhesions are present, if the 
 attempts at movement are repeated after the move- 
 ment has first been made on the sound side, normal 
 action soon commences on the defective side, and 
 is, as a rule, rapidly regained voluntarily. 
 
 VOLUNTARY MOVEMENT. 
 
 Voluntary movement by the patient is in itself 
 better than passive movement, because it not only 
 prevents matting, but is also a potent means of 
 preventing muscle waste, which is not greatly affected 
 by passive movement, except when used in conjunc- 
 tion with methodical massage. Voluntary movement 
 to any great extent cannot, however, be employed 
 with safety until the fracture has become to some 
 
8 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 degree consolidated, in consequence of the strain 
 thrown upon the fractured part ; hence in the imme- 
 diate and early use of movements these should be of 
 the passive kind. The most useful movement of all 
 is the combined passive and voluntary motion, gentle 
 voluntary movements by the patient being aided by 
 passive movement given by the manipulator at the 
 same time. 
 
 The main objection to the use of voluntary move- 
 ment is its liability to cause harmful movements 
 between the ends of the fragments. This, however, 
 is not so important a matter as at first sight may 
 appear, excepting when the fracture involves the 
 shaft of a long bone, and even in such circumstances 
 careful support of the fracture area by the hand of 
 the surgeon, or by means of a well-moulded splint 
 during the voluntary movements of the parts below 
 the break, is generally sufficient to prevent any harm- 
 ful result. In fractures in immediate proximity to 
 joints, and especially in intra-capsular fracture of 
 the neck of the thigh-bone, voluntary movements 
 are, in my experience, always beneficial, unless by 
 chance the pain resulting from them is too acute to 
 allow of their adoption an exceptional occurrence. 
 
 POSTURE. 
 
 For the completely efficient employment of mas- 
 sage and early movements, the proper position of the 
 
INTRODUCTION 9 
 
 affected limb is a matter of much moment. In dis- 
 cussing the treatment of fractures from any point of 
 view, it would at first sight seem superfluous to insist 
 upon a cardinal point like the importance of posture. 
 At the same time, it must be allowed that, obvious as 
 the indications in this direction would naturally seem 
 to be, it is not so commonly followed by practitioners 
 as would be expected. It is, indeed, in the writer's 
 experience not unusual to find this point entirely 
 overlooked, and there is little doubt that many of the 
 unsatisfactory results which are met with after frac- 
 tures are due to the neglect of this rational indication. 
 Pott's fracture may be taken for an example. 
 How often are cases seen in which the injury is treated 
 in the extended portion of the limb with all sorts of 
 contrivances for the prevention of the not unusual 
 deformity caused by the falling back of the foot with 
 resulting elongation of the heel, a characteristic dis- 
 placement in this injury, although it is not mentioned 
 by Pott in his original description of the fracture ; 
 the obviously proper posture being semiflexion either 
 in the manner described by Pott or by the use of 
 that excellent apparatus, Neville's splint, or some 
 similar contrivance. Again, how common it is to 
 see ingenious but useless devices used for retaining 
 in accurate position the fragments in a fracture above 
 the knee, the limb being either nearly straight or 
 at the most slightly flexed upon a double inclined 
 
10 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 plane ; the ideal method being to place the limb 
 in the flexed position, when the fragments almost 
 naturally fall into good position. In all cases treated 
 upon the lines of massage and early movements, 
 care should be taken that the position of the limb 
 is one in which the muscles which are likely to drag 
 upon the fragments are in a state of the greatest 
 rest i.e. speaking generally, the position which is 
 most comfortable to the patient. Further, in frac- 
 tures of the upper end of the femur and of the humerus 
 the indication is to bring the distal fragment in a line 
 with the proximal one, and not by futile plans to 
 endeavour to bring the proximal fragment into a 
 straight line with the distal one. 
 
 Again, in making extension in such cases the fixed 
 point should, when possible, be the knee or elbow, 
 the trunk forming the extending weight. 
 
 CONCLUSIONS. 
 
 A prolonged experience of the use of the com- 
 bined methods of massage, early movements, and 
 rational posture in the treatment of ordinary fractures 
 coming under notice almost daily in hospital work, 
 confirms the writer in the favourable estimate formed 
 by him as reported in his first communication upon 
 the subject in the ' Lancet ' of 1897, and leads to the 
 following conclusions : 
 
 1. When managed with ordinary discretion and 
 
INTRODUCTION 11 
 
 with average dexterity the result of the method is 
 undoubtedly advantageous, inasmuch as the time 
 elapsing before the patient is able to resume his 
 ordinary vocation is diminished by at least one-third, 
 partly by the increased rapidity of union which ensues 
 and to a great extent by the avoidance of the waste 
 of time which occurs in correcting the stiffness and 
 pain which so often follow upon the discontinuance 
 of splints, in the majority of cases treated by means 
 of the classical method of prolonged splinting &c. 
 
 2. The advantages resulting from early passive 
 and voluntary movements an essential precursor 
 of which is massage are especially noteworthy, a 
 fact which was fully elicited in an inquiry made by the 
 present writer in connection with a communication l 
 read at the meeting of the British Medical Associa- 
 tion at Ipswich in 1900, the evidence obtained proving 
 conclusively that early movement is followed by a 
 corresponding early return to the ordinary vocation 
 of the patient. 
 
 3. The benefit of the method is remarkably 
 demonstrated in fractures in which the chances of 
 union without operation are practically nil e.g. intra- 
 capsular fracture of the neck of the thigh-bone the 
 indications being to obtain the best use in the damaged 
 limb by insuring free movement and by preventing 
 the wasting of the muscles concerned ; in such cases 
 massage and movements are indicated at once. 
 
 1 ' The Present Practice in the Treatment of Simple Fractures.' 
 
12 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 4. The danger of thrombosis and embolism feared 
 by some surgeons does not exist more than in frac- 
 tures treated by prolonged splinting. Cases of em- 
 bolism may have occurred in the course of treatment 
 upon the lines under consideration, but the writer, 
 whose experience of the method is probably larger 
 than that of any other surgeon in this country, has 
 met with no such case, although he has seen five 
 instances of embolism (two fatal) in cases of fractures 
 managed by prolonged splinting. Thrombosis and 
 embolism will from time to time occur in fractures 
 however treated, a fact of which any surgeon of 
 large experience must be painfully aware. 
 
 5. The method is not suited to those who lack 
 discretion or who are defective in dexterity a remark 
 which applies with equal force to the majority of 
 surgical methods ; to such the classical treatment by 
 prolonged splinting, whatever its disadvantages may 
 be, is better adapted. 
 
 6. The principal disabilities attaching to the union 
 of fractures in faulty positions, unless the displace- 
 ment be gross or of the rotatory kind, are avoidable 
 by the use of massage and early movements, by which 
 adhesions around the fracture are avoided. 
 
 7. The method is not to be regarded as a substi- 
 tute for treatment by splints on the one hand or by 
 operative measures on the other, but should be used 
 as a rational adjunct to each. 
 
LECTURE I 
 
 THE USE OF MASSAGE AND EARLY MOVEMENTS 
 IN EECENT FRACTURES AND OTHER COMMON INJURIES. 
 
 AT the beginning of February 1898 I called attention 
 in the ' Lancet ' to the use of massage in recent frac- 
 tures, a treatment which had previously received too 
 little notice in this country. After having had some 
 experience of it I then came to the conclusion that, 
 rationally practised, this treatment was probably 
 the best method which could be used in the majority 
 of ordinary fractures, both simple and compound, 
 when the circumstances of the practitioner and of 
 the patient permitted its adoption. The result of 
 that communication was a considerable increase in 
 the use of the method. It has been employed freely 
 in St. George's Hospital with excellent results. 
 Latterly, however, there has been some falling off 
 in its use not because there is anything wrong in the 
 principle of the method or with its results, but because 
 it is at times difficult to keep the necessary number 
 of dressers, who of course are constantly changing, 
 sufficiently instructed in the details to enable it to be 
 
14 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 safely carried out. I have, therefore, thought that it 
 might be useful to devote some time to a practical 
 description of the way in which the treatment should 
 be applied. 
 
 I do not propose to confine my remarks altogether 
 in these lectures to massage in fracture, as I think it 
 will be useful to deal generally also with the legiti- 
 mate use of rational massage in common surgical 
 injuries. In other words, I shall try to say something 
 useful about the treatment of recent fractures, of dis- 
 locations, and of sprains and bruises by the same 
 means. It is possible that I may be able to say some- 
 thing useful about the treatment of each of these 
 varieties of injury ; at all events, I hope the time 
 spent in considering the matter will not be entirely 
 wasted. 
 
 THE USE OF MASSAGE AND EARLY MOVEMENT 
 IN KECENT FRACTURES. 
 
 It is well known that the real difficulties and 
 disappointments in cases of fracture, when they are 
 treated in the ordinary way, often commence after 
 the union has taken place and the patient begins to 
 think of getting about. There are, of course, initial 
 difficulties in connection with the ' setting ' of the 
 bones and in the subsequent keeping of the fragments 
 properly in place ; but these, as a rule, cause no great 
 
OBJECTS OF THE METHOD 15 
 
 trouble provided they are intelligently met. The 
 difficulties in the later stages are mainly pain and 
 stiffness, which frequently require a long and trying 
 course of massage and passive movement to enable 
 the patient to get about with comfort or to follow 
 his occupation, and which sometimes lead to per- 
 manent crippling. In the case, for example, of a 
 fracture of the leg treated in the ordinary way by 
 having been placed in splints or in plaster of Paris, 
 or in some other contrivance of that kind, for a long 
 period, say from six to eight weeks, it will be found 
 that when the splint, of whatever kind it may be, is 
 taken off and the patient begins to walk about or 
 tries to walk about, complaint is frequently made of 
 intolerable pain about the ankle and sometimes across 
 the sole of the foot. The ankle is stiff, the knee may 
 also be stiff, and the muscles are wasted, so that 
 the leg may be little more than bone and skin. 
 Supposing, however, that the case has been treated 
 rationally by massage and movements from the begin- 
 ning, it will be found that the patient is afflicted with 
 none of these troubles ; the ankle is not stiff, there 
 is no pain such as I have mentioned, and the muscles 
 are not wasted, because when massage and early 
 movements are used they are prevented from shrink- 
 ing ; in fact, when the patient begins to get about 
 the ankle is free and supple, and the muscles are 
 almost in the same condition as those of the 
 
16 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 sound limb. These are obvious and great advantages. 
 The reasons of the discomfort which patients suffer 
 when the treatment has been conducted upon classical 
 lines are easily explained. The stiffness is due to the 
 fact that in consequence of the limb having been 
 placed in an immovable splint for a long period the 
 joint included in the splints becomes, as a matter of 
 course, temporarily stiff. If, for example, a perfectly 
 healthy ankle-joint were put into a plaster-of -Paris 
 splint for several months it would be found upon 
 the removal of the splint that the natural mobility 
 of the joint could only be obtained at the expense 
 of some pain and discomfort. In fracture the stiffness 
 is of course infinitely increased by the adhesions of 
 the soft part around the seat of the lesion. 
 
 A noteworthy pain in fracture of the leg is that 
 which shoots downwards from the seat of the fracture 
 along the back of the leg, behind the inner malleolus, 
 and thence into the sole of the foot. This pain is 
 sometimes most acute, and at times leads to per- 
 manent crippling : it is due to neuritis produced 
 by the parts about the fracture becoming matted 
 at the level of the injury ; this matting sometimes 
 involves the posterior tibial nerve, and so gives 
 rise to the neuritis. This condition is no imaginary 
 one, since I have proved it by dissection. 1 The result 
 of this condition is that when the patient begins to 
 
 1 The Lancet, February 5, 1898, p. 359. 
 
OBJECTS OF THE METHOD 17 
 
 try to use the limb after the mere stiffness due to the 
 splints has been overcome, any free movement of the 
 foot causes a dragging upon the adherent nerve, so 
 that an intense neuralgic pain is caused. So acute is 
 this pain in some cases that it prevents the patient 
 proceeding further with attempts to get better move- 
 ment. People are therefore sometimes seen walking 
 with stiff ankles after fractures of the leg which have 
 been treated by persistent splinting, not because the 
 stiffness cannot be overcome, but because the pain on 
 movement of the ankle is so great that they are un- 
 able to bear the necessary manipulation. All this 
 trouble is preventable by the use of intelligent massage 
 and movements in the early stages of the treatment. 
 In the early stages of fracture the main difficulty 
 is, as I have already said, connected with the setting 
 of the bones, the difficulties arising in this respect 
 being mainly three. One is the ordinary nervousness 
 of the patient, which, of course, can only be over- 
 come by tactful management or by the administra- 
 tion of an anaesthetic ; the second is connected with 
 the direction or other peculiarity of the fracture ; and 
 the third difficulty arises from muscular spasm, the 
 result, no doubt, either of irritation of the muscles 
 by sharp edges of bone or of direct laceration of 
 the muscles themselves, which in consequence be- 
 come hypersensitive and excitable. I know of 
 nothing more difficult to relieve under ordinary 
 
 c 
 
18 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 circumstances than the muscular spasm which comes 
 on after the injury in some cases of fracture. Not 
 only is it painful to the patient, but the constant 
 muscular contractions frequently render the retention 
 of the fragments in proper position almost impossible. 
 In the old times and with some people it is even 
 
 FIG. 1. MASSAGE IN EECENT FRACTURE or THE LEG 
 
 STAGE 1 : The Fracture^ set. The limb is secured on a back-splint, with a 
 slightly oblique foot-piece, by bandages at the ankle and knee. Side-splints 
 fixed by webbings or straps complete the fixation of the fracture. 
 
 the custom now it was sought to overcome this spasm 
 by tenotomy ; and since spasm is more commonly 
 met with in the muscles of the calf than elsewhere, 
 division of the tendo Achillis was the operation most 
 frequently performed with this object, because it was 
 thought that division of the tendon would for the 
 time being paralyse the gastrocnemius and soleus, 
 
MODE OF APPLICATION 19 
 
 and would permit of the proper adjustment and 
 retention in position of the fragments which could 
 not be otherwise accomplished. It is not unusual 
 after the reduction of a fracture with or without the 
 aid of an anaesthetic we will, for an example, take 
 the case of the leg to find when the patient recovers 
 consciousness that uncontrollable spasm occurs ; the 
 pain is acute, muscular contraction is inevitable, 
 and if the fracture is at all oblique the displace- 
 ment recurs. Spasm of this kind is more efficiently 
 controlled by massage than by any other plan, 
 excepting perhaps by prolonged general anaesthesia 
 or by narcotism by opium, alternatives which are 
 obviously undesirable in ordinary circumstances. 
 
 Assuming that massage in these cases of recent 
 fracture is right as I have no doubt it is the next 
 point for our consideration is the method of its 
 application. There are, roughly, three stages in the 
 process, and each of these stages effects certain 
 purposes. Naturally, the first thing in every fracture 
 is to ' set ' the broken bones, by which I mean 
 placing them in their proper positions. Nothing 
 short of accurate replacement of the fragments in 
 their proper position should be regarded as a satis- 
 factory ' setting/ The primary point, therefore, to 
 be borne in mind in every case of fracture is that too 
 much trouble cannot be taken in the first instance in 
 getting the bones into position. With regard to the 
 
 c2 
 
20 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 plan of fixing fractured bones in position by the use 
 of screws, nails, pegs, wire, &c., I propose to say 
 nothing here. The method is under certain condi- 
 tions a good one, but it obviously cannot be freely 
 
 FIG. 2. MASSAGE IN RECENT FRACTURE or THE LEG 
 STAGE 2 : Immediate Smooth Rubbing. Commence at any time, the sooner 
 the better, after the fracture has been ' set.' The straps fixing the side- 
 splints are unfastened and the splints are allowed to fall away from the 
 limb. The knee is then steadied by one hand of the manipulator, whilst 
 smooth gentle rubbing from the foot upwards is effected by the other hand, 
 which is made to grasp as much of the circumference of the limb as possible. 
 The time required is from five to ten minutes. The objects are the relief of 
 muscular spasm and rapid absorption of effused blood &c. At the end of 
 this stage the side-splints are replaced, leaving the parts in the condition 
 shown in fig. 1. 
 
 adopted by the ordinary practitioner, although it may 
 produce excellent results in the practice of some of us. 
 Returning from this digression to the method of 
 applying massage, let us suppose that this man before 
 you has a broken leg, somewhere below its middle. 
 
 1 See Present Position of the Treatment of Simple Fractures of the 
 Limbs. 
 
MODE OF APPLICATION 21 
 
 He has come at once to the hospital, and the fracture 
 has been what is commonly called e set 9 ; and as he 
 has come to a great hospital we will suppose it has 
 been properly set. There is a good deal of swelling 
 about the fracture ; there is also a certain amount of 
 muscular spasm. He complains so much of the spasm 
 that unless something is done he can hardly lie quiet, 
 and he certainly cannot sleep or feel comfortable. The 
 ordinary method under such circumstances is to give 
 an hypodermic injection of morphia, or, if the bones 
 are not in precise apposition, to give an anaesthetic 
 if that has not already been done. You will, how- 
 ever, find that unless the bones are out of place- 
 in which case you must at once rectify the defect, 
 under the guidance of the x-rays if these are available 
 gentle rubbing over the fracture, merely a smooth 
 upward movement of the hand which grasps as much 
 of the circumference of the limb as possible, will in a 
 very few minutes, in the majority of cases, practically 
 relieve all spasm. You will sometimes find people 
 who are suffering from spasm to such an extent that 
 they cry out with the pain, and who are certainly 
 unable to get any peaceful rest, after a few smooth 
 passages of the hand over the damaged part settle 
 down comfortably ; in some cases they will actually 
 fall asleep whilst the rubbing is proceeding. This 
 manipulation, however, must be done in the right way 
 that is to say, with the flat of the palm of the hand 
 
22 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 grasping the limb very smoothly and uniformly in 
 the way I show you (vide fig. 2). You need not be in 
 the least degree afraid of passing the hand over the 
 fracture if it is done properly. Patients do not resent 
 the pressure at all in fact, they rather like it, as 
 
 FIG. 3. MASSAGE IN EECENT FRACTURE OF THE LEG 
 
 STAGE 3 : Commencement of Internal Massage. After preliminary smooth 
 massage, as described in Stage 2, one hand of the manipulator is insinuated 
 between the toes of the affected side and the footpiece of the splint (fig. 3). 
 Dorsal flexion is then effected as much as possible by rotating the hand 
 forwards and downwards (vide fig. 4). This movement is repeated from five 
 to ten times, the fracture being steadied by the grasp of the other hand of 
 the manipulator. The date of the commencement of this stage may be any 
 time after the second day. The objects are, early slight movement of the 
 flexor tendons at the back of the ankle to prevent adhesions. Movement of 
 the toes separately instead of en bloc may be substituted at discretion. At 
 the end of this stage the side-splints are replaced as in fig. 1. 
 
 some of you know already from what you have seen 
 in my practice. The first object, then, that massage 
 effects in these cases is the relief of the pain due to 
 spasm should it be present. The same smooth move- 
 
MODE OF APPLICATION 
 
 23 
 
 ment that I am now applying very gently over the 
 swollen parts immediately about the fracture will also 
 bring about absorption of the effused blood with 
 extreme rapidity, so long as the rubbing is smoothly 
 and carefully carried out. The splints used for the 
 treatment of the fracture, you will note, consist of a 
 back-splint with an oblique foot-piece and two straight 
 
 FIG. 4. MASSAGE IN RECEXT FUACTUEE or THE LEG 
 (See fig. 3) 
 
 side-splints, the latter being secured by straps so that 
 they are easily loosened (vide fig. 1). 
 
 Immediate muscular spasm having been allayed 
 in the manner indicated, the side-splints at the end 
 of two or three days are loosened and the limb 
 is left exposed on the back-splint as this man's is 
 
24 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 (vide fig. 2), and every day the massage is employed, 
 at first mainly to get rid of the effused blood round 
 about the fracture. At the end of the third day, 
 again, after practising this smooth massage for ten 
 minutes, passive movement of the muscles and 
 tendons at the back of the ankle and in the calf 
 should commence. In order to effect this you begin 
 very gently by moving the toes only. The foot is 
 still bandaged and the splint remains in the way you 
 see here. The hand is insinuated under the toes in 
 the way I am doing (vide fig. 3) and dorsal flexion of 
 the toes en bloc is made (vide fig. 4). Every time the 
 toes are bent in that way the flexor tendons are 
 pulled upon, and so a little movement is produced. 
 The movement thus produced in the calf accom- 
 plishes the beginning of what is called ' internal 
 massage/ by which I mean that there is a little 
 rubbing movement up and down of the deep muscles 
 in the calf of the leg. This proceeding not only 
 stimulates the circulation, but it makes sufficient 
 movement to prevent immediate adhesions from 
 forming about the fracture, which would otherwise 
 occur. The first passive movement then concerns 
 the toes : this is begun on the third day and con- 
 tinued for two days say, until the fifth day. If all 
 goes well passive movement of the ankle may be 
 commenced from the fifth to the seventh day. For 
 this purpose the limb is allowed to lie quite com- 
 
MODE OF APPLICATION 
 
 25 
 
 fortably, as it will do now, on the back-splint, the 
 side-splints having been removed and the bandage 
 around the ankle taken of?, the bandage above the 
 knee remaining undisturbed (vide fig. 5). The foot 
 
 FIG. 5. MASSAGE IN EECENT FRACTURE OF THE LEG 
 
 STAGE 4 : Increase of Internal Massage. After the usual preliminary smooth 
 massage the bandage fixing the ankle is removed, leaving the limb secured 
 above by the bandage at the knee, and at the seat of fracture by the 
 grasp of one hand of the manipulator. The other hand insinuated between 
 the sole and the foot-piece of the splint firmly but gently grasps the foot 
 and makes passive flexion at the ankle as freely as possible five or six times 
 without moving the fractured bones. The date of commencement of this 
 stage may be any time after the fourth day, but may in difficult cases have 
 to be postponed as late as the eighth or even the tenth day. The object is 
 movement of the ankle-joint and muscles at the back of the leg and the calf 
 to prevent adhesions, especially at the posterior aspect of the fracture. At 
 the end of this stage the splints are replaced as in fig. 1. 
 
 is now firmly grasped with one hand and freely 
 moved at the ankle-joint, the fracture being at the 
 same time steadied by the opposite hand. After a 
 few days the patient may be allowed to make volun- 
 tary movements of the ankle as it lies on the splint, 
 
26 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 the fracture being steadied by the surgeon's hand. 
 Having arrived at this stage of the process all fear of 
 adhesion about the ankle-joint or the parts behind 
 the fracture ceases. It may happen in exceptional 
 cases that the patient is so over-sensitive or the 
 damage to the soft parts so extensive that the plan 
 cannot be carried out with safety, but if employed 
 with intelligence you will rarely find any case in which 
 it cannot be profitably used. For the passive move- 
 ments from three to five minutes at each sitting are 
 sufficient. The passive movements are always pre- 
 ceded by a quarter of an hour's smooth rubbing, 
 by which the patient is generally made most com- 
 fortable, and should be followed by voluntary move- 
 ment, the region of the fracture being supported by 
 the hand. These manipulations are repeated day by 
 day, extending at the end of the first fortnight to 
 as much as half an hour for each sitting. At the 
 end of a fortnight a little more or less, according 
 to the state of union attention should be given 
 to the joint above the fractured point. The 
 joint below the fracture is, however, naturally the 
 most important, because it is that which is most 
 interfered with if adhesions form. At the end, then, 
 of a fortnight or less, after having done what is neces- 
 sary for the leg, the knee may be profitably subjected 
 to passive and voluntary movements. In bending the 
 knee great care must be exercised, because the frac- 
 
MODE OF APPLICATION 27 
 
 ture being only a fortnight old, or a little more, is not 
 in a condition of anything like firm union. The 
 bending of the knee may be carried out in one of two 
 ways. It may be done (1) by simply taking the leg, 
 as you have often seen me do, with one hand under 
 the limb just above the heel and the other grasping it 
 under the thigh in the way shown in fig. 6, and then 
 lifting the knee from the splint. By degrees, as the 
 case goes on, the knee may be raised more and more 
 until at the end of three weeks it is bent up to a right 
 angle. During the whole of these manipulations it 
 must be constantly borne in mind that a recently 
 broken limb is being dealt with. Although that is 
 the plan I adopt in managing these fractures myself 
 in private work or when my masseur or masseuse is 
 managing them for me, it is safer for hospital purposes 
 at this stage, after the massage for the foot and leg has 
 been finished, (2) to put on a pair of short side-splints, 
 retained in position with straps or webbings, and then 
 to bend the knee and ankle in the way I show you 
 (vide fig. 6). This brings the treatment up to about 
 the end of the third week after the receipt of the 
 injury, and by this time in the majority of cases 
 treated on this plan the fracture is nearly sound not 
 sound enough for walking, but sound enough for the 
 patient to be left without any splint. The patient can 
 lie in bed if so disposed, or if he prefers to be getting 
 up and sitting on a couch or chair he may do so after 
 
28 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 having been provided with a case of poroplastic felt 
 or leather to be worn around the calf over the seat 
 of fracture, as a protection. At the end of three 
 weeks you will find that complete ordinary muscle 
 massage may be thoroughly carried out in order to 
 develop the muscles throughout the limb. 
 
 Such is the way in which massage and early 
 movements may be used in any ordinary case of frac- 
 ture of the leg. The nearer the fracture is to a joint 
 the more important it is that this method should be 
 carried out, for the simple reason that the nearer the 
 fracture is to a joint the more likely is it that there 
 will be subsequent pain and stiffness. 
 
 Please understand that the use of massage and 
 passive movement in these cases in no respect lessens the 
 necessity for the point of primary importance in all 
 fractures i.e. placing the fragments at the outset in 
 accurate position. 
 
 Pott's fracture is always a difficult fracture, as is 
 well known, not only on account of the difficulty 
 which often arises in the ' setting ' of it, but because 
 of the matting of parts which is liable to take place 
 afterwards. Once the bones are in good position in 
 this fracture you need have no hesitation in beginning 
 passive movement in two or three days after the 
 injury at the latest, and smooth massage may be 
 commenced directly after the accident with great 
 advantage. Because Pott's fracture happens to so 
 
POTT'S FRACTURE 29 
 
 nearly involve the ankle-joint there is no reason why 
 passive movement should not be used immediately ; 
 on the contrary, this is a strong reason for its adop- 
 tion, for it is only by its use that the avoidance of 
 adhesion and stiffness can be with certainty accom- 
 
 FIG. 6. MASSAGE IN RECENT FRACTURE OF THE LEG 
 
 STAGE 5 : Increase of Passive Movement and commencement of Complete 
 Massage. The back-splint is now dispensed with, the fracture being fixed 
 by means of side-splints straight or with foot-piece (Cline's). These having 
 been removed, the limb is laid on the bed or couch, and complete ordinary 
 massage is applied for fifteen minutes. Unless the union is very firm, the 
 fracture is then fixed by two short splints, or, better, by a poroplastic or 
 leather splint. Passive movements of the ankle and knee are then made in 
 the manner shown in the figure. The flexion at the knee not only prevents 
 stiffness of that joint, but allows more free internal massage by relaxing 
 the calf muscles. The date of commencement may be at any time after the 
 fourteenth day, according to the state of the union. 
 
 plished (vide fig. 7). I have described the case of a 
 fracture of the leg because it is one of the most easy of 
 fractures to manage by this method. When fractures 
 are treated on the lines I have described it will be 
 found, if the practitioner will devote the necessary 
 
30 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 time, and when the sufferer has the patience, that a 
 better result will follow than can be effected by any 
 other plan without operation, and that ultimately the 
 time which is occupied in the complete recovery of 
 the patient is little more than half of that which 
 follows the treatment by splints in the ordinary 
 manner. 
 
 There is one injury in which the effect of the use 
 of this plan from the beginning is most remarkable 
 viz. intracapsular fracture of the neck of the thigh- 
 bone. So far as massage of the part is concerned in 
 a fracture of that kind it cannot be commenced too 
 early. If it is started a few minutes after the injury it 
 is not too soon. In such cases, as you well know, the 
 pain is sometimes very acute, and the spasm is often 
 almost continuous, the patient complaining bitterly 
 of the jumping of the limb and the intense discomfort 
 caused by the spasm. The suffering resulting from 
 the spasm can be removed very rapidly by smooth 
 rubbing of the sort I have described. In such a 
 fracture it is unnecessary to trouble too much about 
 adjustment of the fragments. Excepting cases of 
 impaction, or occasionally when the operation of 
 screwing the fragments together has been immediately 
 adopted, bony union, as you know, rarely occurs, and 
 the indication therefore is to obtain as useful a limb 
 as possible, although there may be no bony union of 
 the fracture. The object in view should be to get a 
 
Plate I. 
 
 'o ^ 
 
 25 
 
 -o 
 
FRACTURE OF NECK OF FEMUR 31 
 
 movable and painless limb with the muscles as strong 
 as possible. No splints should be used. Splints 
 in such cases tend to the production of bed-sores 
 and promote the wasting of muscles. They do no 
 good, and they render the patient most uncom- 
 fortable. Therefore let these cases be treated by 
 
 FIG. 7. MASSAGE IN EECENT FRACTURE or THE LEG 
 
 Showing the amount of voluntary movement at the ankle in a severe case of 
 Pott's fracture two weeks and three days after the injury. When the 
 patient was admitted, immediately after the accident, the foot was displaced 
 completely outward, the transverse horizontal plane of the sole being 
 vertical. The use of all splints was discontinued in the third week. 
 
 smooth rubbing at once and passive movement in 
 24 hours. A masseuse, or any intelligent person with 
 a moderately soft touch, can give more comfort in a 
 case of this kind than all the narcotics and anaesthetics 
 in the pharmacopoeia. In a day or two let passive 
 movement be commenced. Have no anxiety about 
 
32 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 the union,your main objects being to give comfort and 
 prevent muscle-waste : upon the prevention of muscle- 
 waste the ultimate utility of the limb will for the most 
 part depend. The worst thing that can happen in 
 cases of this kind is wasting of the muscles, which can 
 be obviated by intelligent massage and movements. 
 This, then, is the treatment under ordinary circum- 
 stances which I strongly commend to your notice 
 in such cases. The use of a splint should be altogether 
 avoided, smooth massage should be commenced at 
 once, passive movement should follow quickly, 
 flexion and extension should be effected by lifting the 
 knee from the bed in the way I show you (fig. 6), 
 and rotation movements should be the last to be 
 practised. For the first three or four days let passive 
 flexion and extension be made as often as possible ; 
 no pain occurs if the limb has been previously rubbed 
 smoothly and gently. In a week or two rotation 
 may be used. At the end of a week voluntary move- 
 ments should be encouraged as much as possible. 
 Under no circumstances should any passive move- 
 ment whatever be employed until the neighbourhood 
 of the injury has been subjected to a good smooth 
 rubbing. You may use liniments or not, as you 
 please, but it is the rubbing which does the good. 
 
 There are few fractures in the whole body which 
 were formerly followed so frequently, I suppose, by 
 a certain amount of defective movement as Colles's 
 
COLLES'S FRACTURE 33 
 
 fracture, the result almost entirely of the matting of 
 the parts. Sometimes it is said that the defects 
 which follow in Colles's fracture are entirely due to 
 the alteration in the relations of the bones produced 
 by the injury. In certain of the cases the bones 
 remain without doubt altered in their relations to one 
 another, but the cause of the want of movement does 
 not, as a rule, lie with the altered bone relations. 
 The cause of the want of proper movement is nearly 
 always adhesions and nothing more, and if these cases 
 are treated intelligently by massage and movements 
 from the first there is little fear of defective results. 
 The method I use in such cases is as follows : The 
 fracture having been ' set/ the forearm is placed upon 
 one of the many kinds of splints which have been 
 devised for this fracture Carr's splints being, I think, 
 on the whole the best ; but the kind of splint is im- 
 material so long as the anterior splint is placed well 
 behind the bases of the fingers. Before the back- 
 splint is applied gentle smooth rubbing should be 
 used, the patient being immediately told to flex and 
 extend the fingers as much as possible and as often as 
 possible. The back-splint should from the first be re- 
 moved daily for smooth rubbing. In two or three 
 days a little gentle backward passive movement at the 
 wrist should be made whilst the part lies exposed on 
 the anterior splint after the smooth rubbing. In 
 from four to six days after the injury the part should 
 
 D 
 
34 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 be gently lifted off the splint after the usual smooth 
 rubbing and held by the manipulator with one hand 
 firmly grasping the fracture area whilst the other 
 hand flexes and extends the wrist a few times in 
 succession (fig. 8). This is repeated daily, the amount 
 
 FIG. 8 
 
 A drawing by Mr. Mummery, F.E.C.S., showing the amount of voluntary move- 
 ment, obtainable nine days after the injury in a case of Colles's fracture 
 treated by this method. The manner in which the fracture is steadied by 
 the grasp of the practitioner during its temporary removal from the splint 
 should be noted. From an article by the Author in the ' Practitioner,' 
 August 1901. 
 
 of movement increasing gradually as time goes on. 
 In a week the patient may be allowed to make 
 the movements freely of his own accord after he has 
 been provided with a poroplastic or leather splint 
 which is easily removed and replaced. Ordinary 
 
FRACTURES NEAR SHOULDER-JOINT 35 
 
 complete massage is at the same time commenced 
 daily. At the end of three weeks all splints may- 
 be discarded, the arm being carried in a sling for 
 another week only. 
 
 Again, let me impress upon you the fact that the 
 most important practical point to be borne in mind 
 in connection with the use of passive movement 
 in cases of recent fracture and other injuries is this : 
 passive movement should always be preceded by smooth 
 massage, which soothes the irritable muscles so completely 
 that movements of the most complete kind are readily 
 employed without exciting muscular contraction of a 
 harmful sort. If, on the other hand, passive move- 
 ment is abruptly attempted without preparing the 
 muscles by previous smooth rubbing violent muscular 
 action generally occurs, which is not only painful to 
 the patient, but tends to throw the fractured bones 
 out of place. There is, I am sure, no dictum in 
 surgery which is more sound than this : In all 
 cases in which passive movement is practised smooth 
 muscle massage should precede the movement. 
 
 Another set of fractures which may be treated by 
 this method with a result which, speaking generally, 
 surpasses that of any other plan are those occurring 
 in the immediate neighbourhood of the shoulder- 
 joint. The difficulties under ordinary circumstances 
 of dealing with such fractures are too well known 
 to require comment. I am now referring to fractures 
 
 D2 
 
36 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 of the extreme upper end of the humerus and of the 
 scapula close to, or involving, the shoulder- joint. 
 It is a matter, I suppose, of common knowledge 
 that such fractures are followed much more fre- 
 quently than some people suppose by stiffness of 
 the shoulder- joint. It is, in fact, not uncommon 
 to find upon examining a patient at a long interval 
 after a fracture of this sort that the shoulder- joint 
 is quite fixed, although the patient may be ignorant 
 of the fact. Many patients who have sustained 
 an injury of the kind I am now discussing com- 
 plain continually of acute pain in attempting to 
 raise the arm beyond a right angle from the body. 
 In the case of the majority of patients who complain 
 in this way an examination will show that the scapula 
 in the movement mentioned moves with the humerus, 
 and that movement in the shoulder- joint is practi- 
 cally nil. In fact, a considerable proportion of people 
 who have sustained this kind of injury, especially 
 if the lesion has been treated by means of continuous 
 splinting or fixed apparatus, never regain free move- 
 ment in the joint. 
 
 The method which I use, because it has given 
 me the best results, in all these fractures about the 
 shoulder in the immediate vicinity of the joint, 
 whether the lesion is of the humerus or of the. scapula, 
 commences with smooth rubbing in the ordinary 
 way at once. From the beginning of the case I 
 
Plate II. 
 
 A case of fracture of the liumerus, showing faulty position of the 
 fragments. The accident occurred at sea. The only treatment the 
 patient received was at the hands of the ship's mate. The result is 
 shown in Plate III. 
 
Plate III. 
 
 JJ 
 
 it 
 
 1 
 
 jj 
 
 Photographs showing range of movements attainable by the patient in the case shown 
 in Plate II. thirteen months after the injury, the patient having been doing the duties of 
 an ordinary seaman from a few weeks after the injury. 
 
FRACTURES NEAR SHOULDER-JOINT 37 
 
 use passive movement very gently indeed. One 
 hand is placed on the shoulder, gripping the part 
 as a whole. This fixes the shoulder-girdle. To- 
 and-fro movements of the arm are then gently made, 
 especial care being taken to avoid rotation. If 
 rotation is made movements between the fragments 
 are liable to follow freely, and so union may be 
 delayed or prevented. You need have no fear of 
 harm coming from antero-posterior movement. At 
 the end of three or four days gentle abduction from 
 the side of the trunk is commenced ; at the end of a 
 fortnight circumduction may be gently carried out, 
 and voluntary movements used. Rotation should 
 not be attempted for at least a fortnight, after 
 which rotatory movements should be daily made. 
 For these fractures near the joint I do not use splints, 
 excepting a protective shoulder cap of leather or 
 poroplastic felt retained in position by straps so that 
 it can readily be removed for the daily massage ; 
 nor do I use pads in the axilla. The arm is merely 
 allowed to rest in a sling. By this method the treat- 
 ment of cases of fracture close to the shoulder- joint 
 may be completed in three weeks, and I have never 
 seen such good results attained in so short a time 
 by any other plan. If in such cases the parts are 
 confined in splints for long periods a stiff shoulder- 
 joint follows, as I have already said, much more 
 commonly than is generally supposed a statement 
 
38 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 which, can easily be verified by the examination of 
 cases so treated at long periods (say nine months 
 or one year) after the injuries. 
 
 The results obtainable by this method in fractures 
 involving the elbow- joint are very remarkable. In 
 such cases when the damage is great and the bones, 
 as shown by the #-rays, greatly displaced, the adjust- 
 ment and fixing the fragments by means of screws, 
 pegs, or wire provide the ideal treatment, but this 
 is not always practicable ; indeed, it is obvious that 
 only a small minority of cases of this kind comes 
 under the care of those who are in a position to use 
 these operative measures. 
 
 Plate IV. represents a case of the kind which 
 was under my care at the Seamen's Hospital, 
 Greenwich, operation having been declined by the 
 patient. 
 
 In six weeks from the date of the accident the 
 movements of the part were nearly normal in extent 
 and the muscles strong. It is doubtful whether as 
 good a result could have been obtained even by 
 operation in the most practised hands. 
 
 It would obviously be impossible within the limits 
 of lectures like these to give the details of the treat- 
 ment of every kind of fracture, but the examples 
 I have described give a fair idea of the principles of 
 the plan, which can readily be applied by any intel- 
 ligent person. It is a method of treatment which 
 
Plate IV. 
 
 ... 
 
 Photographs showing range of voluntary movement, 24 days after the accident, in a 
 comminuted fracture of the humerus involving the elbow joint, treated without operation 
 by early movements and massage. In six weeks, with the exception of a very slight 
 limitation in flexion, the movements were as free as those on the opposite side. 
 
FRACTURES NEAR SHOULDER-JOINT 
 
 39 
 
 must be conducted with discretion. In compound 
 fracture it is not always practicable in the early 
 stages, but after the wound has healed it can be 
 used as if the case were one of simple fracture, 
 and in the earliest stages of many compound fractures 
 
 FIG. 9. MASSAGE AND EARLY MOVEMENT IN RECENT FRACTURES 
 
 Showing the amount of movement and the general condition of the left lower 
 limb in a case of fracture through the condyles into the knee-joint six weeks 
 after the injury. The limb is shown in complete extension and in flexion, 
 the effect being produced in the photograph by taking the limb in the two 
 positions upon the same plate (see also fig. 7). At the date upon which 
 the photograph was taken the patient was up and walking about the ward 
 freely with a hardly perceptible limp. The absence of wasting of the limb 
 generally is noteworthy. 
 
 there is no reason why passive movement of the joint 
 most likely to be concerned should not be practised 
 at once, although the fact that the manipulations 
 
40 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 cannot at first be preceded by smooth massage 
 places the practitioner at some disadvantage in such 
 cases. In young children, again, there may be 
 difficulties in using the method in its entirety, but 
 even in these cases it is quite curious how a frightened 
 child with a fractured limb can be soothed by gentle 
 massage of the part. 
 
 The great advantages of the treatment are : (1) the 
 ease with which the patient is made comfortable 
 by arresting the muscular spasm, and so relieving 
 the pain ; (2) the effecting of rapid absorption of 
 effused blood &c. ; (3) the prevention of stiffness 
 by obviating the formation of adhesions ; (4) the 
 prevention of muscle-wasting and the preservation 
 throughout the case of the normal nutrition of the 
 limb ; and (5) the shortening of the time by about 
 half during which the patient is prevented from 
 resuming the ordinary use of the limb. 
 
 The only real objections to the plan are, I think: 
 (1) the difficulty which must often arise in carrying 
 it out, as unless a competent masseur or masseuse is 
 available the time required must frequently be more 
 than the ordinary practitioner can spare ; and (2) the 
 fact that the treatment is one requiring so much 
 intelligence and discretion in the mode of its appli- 
 cation that it may be difficult at all times to find 
 a person to whom it may be entrusted with safety 
 when the practitioner is not prepared to manage 
 
OBJECTIONS TO THE METHOD 41 
 
 the details himself. The objection which has been 
 raised on the ground that harmful movements of the 
 fractured bones must result is of no value if the 
 treatment is properly carried out, as the movement 
 is then practically nil, and certainly not enough to 
 prevent union in any degree whatever. What the 
 results of the treatment of recent fractures by mas- 
 sage in the hands of others has been I do not know, 
 but so far as my experience is concerned the results 
 are far superior in the majority of cases to those 
 obtainable in any other way. I am not acquainted, 
 for example, with any other treatment by which the 
 results depicted in figs. 7 and 9 could be obtained 
 in an extremely severe case of Pott's fracture, and in a 
 case of fracture into the knee-joint. With increasing 
 experience of the method my belief in it has steadily 
 become more sure. 
 

 Sl 
 
 Hrll 
 
 3 '- S 
 
 '& o ^ 8 
 
 O-U> ^^'? 
 
 11- 8 .! 
 
FRACTURE OF THE PATELLA 43 
 
 LECTURE II 
 
 THE USE OF MASSAGE AND EARLY MOVEMENTS IN 
 RECENT FRACTURES AND OTHER COMMON INJURIES 
 
 (continued) 
 
 IN my previous lecture the expiration of the time 
 at my disposal compelled me to omit any mention 
 of two varieties of fractures of considerable impor- 
 tance from the point of view of the treatment by 
 the use of immediate massage viz. fracture of the 
 patella and of the olecranon. Until recently, as you 
 know, the classical method of treating these fractures 
 was by long confinement in splints or fixed apparatus 
 (the period in the case of fracture of the patella ex- 
 tending sometimes to as much as a year or even more), 
 with the object of obtaining as firm a union between 
 the fragments as possible. Under such circumstances 
 it cannot be considered remarkable that in many cases 
 the difficulty in obtaining free movement in the knee- 
 joint at the end of the splinting period was extreme, 
 and that in some cases, indeed, the pain and distress 
 entailed in the necessary treatment were more than 
 the patients could endure. So great, indeed, was 
 
44 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 the pain sometimes under these circumstances that 
 a certain number of people who had sustained a 
 fracture of the knee-cap, rather than bear the pain 
 entailed in getting free movement, preferred to 
 remain with the limb more or less stiff. Speaking 
 generally, the stiffness that follows upon a fracture 
 of the patella, treated upon the old lines, depends 
 largely on the fixation of the upper fragment to the 
 anterior aspect of the femur at the time when attempts 
 at movement are commenced not, of course, by 
 bony ankylosis, but by adhesions which, forming 
 around the margin of the knee-cap, so tighten the 
 soft parts about it that it is for practical purposes 
 sealed to the surface of the femur. In attempting to 
 get movements in these cases when treated, as I have 
 said, in the olden way, no really good result could 
 be obtained until these adhesions, as well as those 
 in the joint, were loosened a difficult and pain- 
 ful process which was rendered necessary merely 
 because the parts had been confined so long in 
 splints without movement. Moreover, the strain put 
 upon the parts under these circumstances frequently 
 led to a great stretching and sometimes laceration 
 of the uniting medium. The upper fragment of 
 the patella remained, in fact, at first fixed, and 
 before the exercises had resulted in the breaking down 
 of the adhesions, movement was often obtained 
 at the expense of the stretching of the union, the 
 
FRACTURE OF THE PATELLA 45 
 
 stretching in some cases being very great ; but even 
 in such cases, so long as the upper fragment ultimately 
 became freely movable upon the femur, a fairly good 
 limb resulted in the majority. In the absence of the 
 treatment by suture now so commonly employed the 
 final result is dependent mainly upon two points : 
 (1) the amount of laceration of the lateral expansions 
 about the knee at the time of the injury (the less the 
 lateral expansions are ruptured the more strength is 
 there left in the joint after the fracture) ; l and (2) the 
 amount of mobility finally retained by the upper 
 fragment of the patella. If the fragment does not 
 contract inveterate adhesions, and finally becomes 
 freely movable upon the femur, a more or less useful 
 limb follows, the strength of the limb, as a rule, then 
 being in inverse ratio to the length of the uniting 
 medium. If, on the other hand, fixation of this upper 
 fragment occurs, then the interference with the 
 mobility and strength of the joint is so great that 
 the patient is much crippled. 
 
 The first object, then, in a case of a fracture of 
 the patella, whether wiring has been practised or not, 
 is to prevent by constant manipulation any chance of 
 adhesions forming around the upper fragment and 
 fixing it to the femur a treatment which excludes 
 any form of splint which makes the patella inaccessible. 
 This necessity for securing free mobility of the patella 
 
 1 See Present Position of the Treatment of Simple Fractures. 
 
46 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 is not confined to cases of fracture, but if a rapid and 
 perfect result is to be obtained it should be used in 
 all cases of inflammation of the knee-joint, traumatic 
 or otherwise, liable to be followed by stiffness. This 
 is a point to which reference will again be made. 
 
 As I have already said, this method of treatment 
 makes the use of fixed immovable apparatus impos- 
 sible, such, for example, as plaster of Paris, silicate 
 of potash and the like. I may at once state that I 
 have no doubt that the sooner these stiff, immovable 
 appliances become obsolete the better it will be in 
 all cases of damage of joints and in the neighbourhood 
 of joints. The stiffness and pain which so often 
 followed in fracture of the patella when treated 
 upon the old lines were much more frequently due 
 to the treatment than to the injury. The best 
 results which follow fracture of the patella when not 
 subjected to the wiring treatment will be obtained 
 by immediate smooth massage and patellar manipu- 
 lation, followed in a fortnight or earlier by gentle 
 passive movement of the knee, during which the upper 
 fragment should be firmly fixed by the hand of the 
 manipulator in order to prevent its being drawn up 
 towards the thigh. By this means, if effectually 
 managed, flexion to a right angle can generally be 
 accomplished without increasing the separation. 
 In this way, in the majority of instances, a useful 
 limb may be expected in from three to six months, 
 
FRACTURE OF THE OLECRANON 47 
 
 all splints being discarded at the end of the first 
 month. It is remarkable how little, if any, stretching 
 of the union occurs in cases treated in this manner 
 when care is taken from the outset to secure free move- 
 ment of the patella upon the femur. 
 
 The same observations apply with equal weight 
 in the case of fracture of the olecranon. It will be 
 found upon examination that in the majority of cases 
 of fracture of the olecranon treated by long-continued 
 immobility in splints the detached fragment of the 
 olecranon is fixed to the humerus. I do not mean 
 that it is always fixed by bony ankylosis, but it is 
 connected to the humerus by such strong adhesions 
 that it is very difficult to move it at all. Further, 
 it will be found that the utility of the limb in such 
 cases is in direct proportion to the mobility of the 
 detached fragment upon the humerus in fact, the 
 utility of the limb depends more upon this factor than 
 upon the apparent strength of the union. When the 
 fragment is fixed it will be found upon commencing 
 to bend the joint that movement is obtained, not 
 by the gliding downwards of the upper fragment 
 upon the humerus, as should be the case, but by a 
 stretching of the union, the fragment remaining fixed ; 
 and in such cases, although flexion may be effected 
 to a great degree, and sometimes completely, extension 
 power is almost, if not entirely, wanting. So much 
 is this sometimes the case in exaggerated instances 
 
48 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 that although the patient may be able to semiflex 
 the arm or, perhaps, to flex it completely, if the 
 limb is raised above the shoulder or by the side of the 
 
 * . 
 
 H S,S fl 
 
 lifl 
 
 tf .IS* 
 
 8 E : 
 
 w 4^ 
 
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 I .a ^ 
 
 HI 
 
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 02 
 
 head the forearm falls down almost as in a paralysed 
 limb in consequence of the triceps having lost its 
 power from the fixation of the detached olecranon 
 
FRACTURE OF THE OLECRANON 49 
 
 to the lower end of the humerus. If in the treatment 
 of such a case trouble be taken during its early pro- 
 gress to constantly move the detached portion of 
 the olecranon upon the humerus by a little gentle 
 flexion and by lateral manipulation, care being taken 
 that in flexion the detached fragment is made to follow 
 the movements of the forearm, which is easily done 
 by making pressure upon it in a downward direction 
 during passive movement, all adhesion is prevented 
 and the patient probably recovers with a limb which 
 is practically almost as useful as if there had been no 
 fracture at all the utility of the limb here, as in 
 fracture of the patella, when the union is fibrous, 
 depending upon the freedom of movement of the 
 detached fragment as much as or, indeed, more than 
 upon the actual strength of the uniting medium. 
 
 The two cardinal facts to bear in mind in the 
 rational treatment of fracture of the patella and 
 fracture of the olecranon are these : 1. The avoid- 
 ance under all circumstances of any chance of the 
 upper part of the patella or of the olecranon be- 
 coming adherent to the subjacent bone. Such ad- 
 hesion may be prevented by massage and lateral 
 manipulation combined with gentle flexion and ex- 
 tension, during which the detached fragment is made 
 to move as much as possible with the distal portion 
 of the limb i.e. with the leg or forearm as the case 
 may be the lateral movement being the most 
 
 E 
 
50 MASSAGE AND MOVEMENTS IN FRACTURES 
 
 readily managed and resulting in the least disturb- 
 ance of the parts generally. 2. All manipulation and 
 passive movement should be preceded by smooth 
 rubbing of the muscles. By this treatment you will 
 in the majority of cases provide the patient with a 
 limb which is useful to an extraordinary degree 
 beyond that which follows when this plan is not 
 used. I am, of course, speaking generally only, 
 because occasionally a case treated by other methods 
 without operation will leave a sound and good limb, 
 but many of the cases so treated are very imperfect 
 both in movement and in power. 
 
 When the fracture of an olecranon is treated by 
 wiring, screws, or pegs the same cardinal points 
 must be borne in mind. Massage and passive move- 
 ment cannot be practised too soon, nor can the patient 
 be encouraged too soon to use gentle voluntary 
 movement at the elbow- joint. 
 
 I may perhaps be allowed a moment's digression 
 here to explain, in order to avoid any misunder- 
 standing, that the remarks which I have just made 
 must not be held to imply that I have any wish to 
 substitute in a general way treatment by massage 
 and manipulation for the operative measures now so 
 commonly employed in fractures of the olecranon 
 and patella. I am second to none in my estimation 
 of the value of these measures ; but there must 
 always remain a number of cases which, for reasons 
 
MASSAGE AND MOVEMENTS IN DISLOCATIONS 51 
 
 which it would be foreign to my present purpose to 
 discuss, are not suitable for operation some in 
 themselves, some because the patient does not desire 
 operation, and some in consequence of the circum- 
 stances in which the practitioner finds himself being 
 not such as to justify his undertaking operative 
 measures. In such cases intelligent massage and 
 manipulation will produce a better result than any 
 other plan, and in many instances will restore the 
 limb to a degree of usefulness which cannot even be 
 excelled by operative treatment. 
 
 IMMEDIATE MASSAGE AND MANIPULATION IN 
 DISLOCATIONS. 
 
 For the better* understanding of the remarks 
 which follow it is necessary to insist upon certain 
 elementary points. If a dislocation is complete in 
 the ordinary acceptation of the term the capsule 
 of the joint must, as a matter of course, be torn, 
 the rent in the capsule being of large or of small 
 extent. The obstacles to the reduction of a dis- 
 location depend comparatively little, as a rule, 
 upon the situation or character of the laceration 
 in the capsule ; occasionally only do some of the 
 difficulties met with in attempts at reduction lie with 
 this structure. The real difficulty is for the most 
 part due to muscular contraction a fact which is 
 amply proved by the manner in which most difficult 
 
 E2 
 
52 MASSAGE AND MOVEMENTS IN DISLOCATIONS 
 
 dislocations will often reduce themselves as soon as 
 the patient is fully anaesthetised. The longer a 
 dislocation remains unreduced the more marked 
 does this contraction of the muscles become, and 
 the more difficult is it. to remove the bone from its 
 abnormal site. Supposing that a dislocation remains 
 unreduced for five, or six, or eight weeks in a joint 
 such as, for an example, the shoulder, physiological 
 shortening of the muscles takes place ; and in con- 
 sequence a reduction of the dislocation by ordinary 
 means may become practically impossible. I mention 
 these facts, not because I suppose you are unfamiliar 
 with them, but because I wish to emphasise as strongly 
 as possible the importance of muscular contraction 
 and shortening as obstacles to reduction in the vast 
 majority of the dislocations with which we are 
 ordinarily called upon to deal. For practical pur- 
 poses the capsule and surrounding bony points may 
 be ignored, since if they form any obstacle to reduc- 
 tion it is generally secondary to the condition of the 
 muscles. 
 
 It is further a most important point to bear in 
 mind that under ordinary circumstances after the 
 reduction of a dislocation the retention of the re- 
 placed bone in its normal site depends not so much 
 upon the state of the capsule, which in reality has 
 little to do with the matter, as upon the muscles, 
 aided in certain cases by atmospheric pressure. In 
 
MASSAGE AND MOVEMENTS IN DISLOCATIONS 53 
 
 fact, the question of the healing of the rent in the 
 capsule is of small importance compared with that 
 affecting muscle-waste. The capsule will heal equally 
 well whether the joint be kept fixed in splints or 
 whether it be subjected to passive movement from 
 the first. The muscles about the j oint , especially those 
 supplied by the same nerves as supply the articulation, 
 waste rapidly if the joint be kept fixed for ever so short 
 a time, and if the fixation be kept up for long periods 
 this wasting may proceed so far as to be incurable. 
 On the other hand, if massage and passive movement 
 be at once commenced, then wasting can be entirely 
 prevented, in the absence, of course, of actual nervous 
 lesion. If the muscles are allowed to waste to any 
 great extent, as you can easily see for yourselves by 
 watching an ordinary case, the whole joint becomes 
 loose and flabby. There is no such thing as a pri- 
 mary tonic condition of the capsule of the joint : 
 the capsule of the joint is a passive structure, and has 
 no contractile vitality of any sort beyond that which 
 it derives from muscular attachments and expansions. 
 The prolonged fixation of a joint after the reduc- 
 tion of a dislocation allows the muscles to waste, 
 which is tantamount to bringing about the precise 
 conditions which tend to recurrent dislocation if 
 attempts to obtain free movement are made at a later 
 period. The effect of even temporary fixation of a 
 joint in the production of adhesions which have sub- 
 
54 MASSAGE AND MOVEMENTS IN DISLOCATIONS 
 
 se^uently to be treated, often for long periods, I need 
 hardly, I suppose, impress upon you ; although I 
 fancy that if you were to examine a large number 
 of patients who have had dislocations, say of the 
 shoulder-joint, at a long period after the injury, you 
 would be surprised to find that the percentage of 
 cases in which some stiffness still persists from this 
 cause is very considerable. 
 
 In the practice of the older school of surgeons 
 prolonged fixation of a joint after dislocation was 
 almost universal, the main object being to allow of a 
 firm and rapid union of the rent in the capsule. So 
 much was thought of the value of the healed capsule in 
 retaining the parts in position that the disadvantages 
 of adhesions and muscle-waste were held to be of no 
 account compared with the vital importance of the 
 completely restored capsule. I strongly recommend 
 you to reverse these conditions by concentrating 
 your attention upon measures for the avoidance 
 of adhesions and muscle- waste. Ignore the torn 
 capsule ; the rent will heal soundly in spite of any 
 rational manipulations or movement it may be 
 subjected to in treatment. Ingenious operations 
 which from the nature of things cannot effect material 
 good have been from time to time invented with 
 a view to the cure of recurrent dislocation by shorten- 
 ing the loose capsules, the fact having been over- 
 looked or forgotten that looseness of the capsule 
 
MASSAGE AND MOVEMENTS IN DISLOCATIONS 55 
 
 is secondary to muscle-waste, which is the real thing 
 to be combated. The only available method by 
 which muscle-waste can be avoided in these cases of 
 dislocation, especially of the shoulder, is massage, 
 commencing immediately after the reduction of the 
 displacement smooth rubbing only for the first two 
 days, after which passive movement follows the 
 massage. This passive movement may be very free in 
 all directions save that which is towards the muscles 
 which tend to waste. For example, in the case of 
 the shoulder, abduction of the arm from the trunk 
 should not be practised for a week or ten days after the 
 injury, because the strong action of the adductors, 
 unopposed for the time being by the weakened deltoid, 
 tends to displace the head of the humerus inwards. 
 For the same reason in the first week no voluntary 
 movement should be allowed, all movements being 
 passive. Treated on these lines any dislocation of a 
 major joint e.g. shoulder or hip may be cured in 
 from two to three weeks without adhesions and with 
 no stiffness remaining. At the end of a week, or at 
 the most ten days, from the date of the injury, free 
 voluntary movements should follow. 
 
 All cases of recurrent dislocation will be found to 
 be associated with marked muscle-waste. The car- 
 dinal principle in treatment is in the direction of 
 rectifying the atrophy of the muscles by massage 
 and methodical exercises with or without electricity, 
 
56 MASSAGE AND MOVEMENTS IN DISLOCATIONS 
 
 and not in the direction of shortening the lax capsule 
 by operation. 
 
 The beneficial effect of massage in dislocations is 
 not limited to the treatment after reduction ; it is 
 sometimes of great use as an aid to reduction. The 
 following case will serve as an illustration of this 
 point. A highly sensitive and nervous lady, con- 
 siderably beyond middle age, dislocated her shoulder 
 in a fall which followed a slip on some parquet 
 flooring. There was extreme pain, and the muscular 
 spasm was intense, the least attempt to move the 
 parts eliciting loud cries from the patient. Whilst 
 waiting for the arrival of an anaesthetist, as the 
 muscular spasm was so great, I gently massaged 
 the region of the shoulder, upon which the pain 
 was soon modified and by degrees disappeared. 
 In the course of the rubbing I noticed that the 
 muscles became less hard, and especially I observed 
 that the hollow tension of the deltoid was succeeded by 
 a feeling of almost softness. Seizing the favourable 
 moment I passed my right hand into the axilla and 
 with a sudden outward jerk reduced the dislocation 
 easily (the displacement was sub-glenoid) ; in fact, 
 had an anaesthetic been administered reduction could 
 not have been more easily effected. In two other 
 cases of dislocation of the shoulder of a similar kind, 
 one being sub-coracoid, the other sub-glenoid, I have 
 in the same way effected reduction with remarkable 
 
MASSAGE AS AN AID TO REDUCTION 57 
 
 ease. Cases like these show further the point I have 
 already insisted upon viz. the importance of con- 
 centrating your mind upon the condition of the 
 muscles in cases of dislocation. 
 
 Before leaving the subject of dislocations allow 
 me again to refer to the question of muscle- waste in 
 these cases, because I do not think that in some in- 
 stances it is sufficiently understood. In the case of 
 the fleshy joints e.g. the shoulder and hip muscle- 
 waste, unless the massage treatment is adopted, is too 
 obvious to require comment. Wasting in the same 
 manner occurs uniformly in all dislocations, although 
 it certainly is not recognised by some people. The 
 wasting, for instance, of the quadriceps in certain 
 conditions of the knee is of common knowledge, but 
 I venture to think that the wasting of the muscles 
 controlling the ilio-tibial band is but little realised. 1 
 Again, it would at first sight seem almost impossible 
 that any wasting of muscles should follow upon disloca- 
 tions of distal joints like those of the phalanges of the 
 fingers which are quite remote from muscular bellies ; 
 yet in these it will be found, if examination be made, 
 that there is universally some wasting of the forearm, 
 and, further, that the permanent sense of weakening 
 which is complained of by some of the patients who 
 have suffered from these injuries can only be rectified 
 by voluntary exercises or by thorough massage of the 
 
 1 See Injuries and Diseases of the Knee-joint, by the present writer. 
 
58 MASSAGE AND MOVEMENTS IN SPRAINS 
 
 forearm muscles. The bearing of these points upon 
 the scientific treatment of these injuries is too obvious 
 to require explanation ; it is, I am sure, of much 
 more importance than is commonly thought. It 
 would, of course, be interesting to describe seriatim 
 and in detail the management of the various disloca- 
 tions throughout the body by immediate massage and 
 passive movement, but time will not allow of this. 
 I hope, however, that what I have been able to say 
 will be sufficient to indicate the general principles 
 upon which the treatment should be conducted. Its 
 modification to the requirements of the different 
 joints is merely a matter for the exercise of ordinary 
 intelligence. 
 
 IMMEDIATE MASSAGE IN SPRAINS, WRENCHES, 
 AND BRUISES. 
 
 As is the case with dislocations, the objects to be 
 attained in the treatment of sprains, wrenches, and 
 bruises are the restoration to the normal state by the 
 rapid removal of effused products, the prevention of 
 adhesions, and the avoidance of muscle- waste. Any 
 treatment which fails to obtain these ends is defective. 
 Further, it is, I am sure, undeniable that the only 
 plan of treatment which will attain the desired end 
 with certainty and in a reasonable time is that of 
 immediate massage and very early passive move- 
 ment a plan which is, if intelligently used, appli- 
 
MASSAGE AND MOVEMENTS IN SPRAINS 59 
 
 cable universally, with the exception, perhaps, of a 
 few special cases. 
 
 First, with regard to sprains. For our present 
 purpose by a sprain is meant an injury to a joint, 
 a muscle, or other soft part by a wrench, a bend, or a 
 twist. There is always some laceration of the tissues, 
 but there may be no open wound. In the case of a 
 joint the injury always involves some tearing of the 
 fibres of the capsule, synovial apparatus, or cartilage. 
 There is pain of variable degrees, and there may or 
 may not be effusion into the joint. Generally, if the 
 sprain is of any severity there is effusion into the 
 joint ; if the effusion follows immediately upon the 
 injury it is blood ; if it follows a day or two sub- 
 sequently it is due to synovitis. I must again crave 
 indulgence for emphasising such elementary points. 
 The occurrence of this laceration in cases of sprain 
 which means, of course, a subcutaneous wound led 
 to the faulty practice of former times, which is even 
 now, I fear, far too prevalent, of placing parts so 
 injured for a long period in splints : the best possible 
 method for facilitating the formation of adhesions and 
 the perpetuation of muscle- waste, the main object of 
 this mistaken treatment being to allow of the rapid 
 healing of the wounded tissues a point of com- 
 paratively small importance. 
 
 In order to make clear the plan of treatment 
 which I use, and which I strongly advise you to 
 
60 MASSAGE AND MOVEMENTS IN SPRAINS 
 
 adopt in these injuries, let us take the case of a 
 man who has sprained his knee. At the time of his 
 coming under observation say, a few hours after the 
 injury the jpint is painful, swollen from effusion 
 (probably for the most part blood), and any attempt 
 at movement of the joint is resisted. The first 
 indication is the removal of the effusion. With this 
 object the patient is, if possible, sent to bed and the 
 limb is placed upon a light back-splint a ham-splint 
 being the most convenient applied so that free 
 access is left to the joint. Gentle smooth massage 
 over the swollen joint is commenced at once. In 
 very severe cases this is sometimes resented at first 
 by the patient, whose resentment, however, soon 
 subsides when he realises the soothing effect which 
 the gentle rubbing produces. In the intervals of 
 the rubbing fomentations of lead and opium may be 
 laid upon the joint ; the opium soothes somewhat, 
 and the lead hardens the skin a little, which is useful 
 in the subsequent management. From the first gentle 
 passive movement of the patella is used, for the 
 reasons which I have already sufficiently indicated. 
 As soon as the effusion has distinctly commenced to 
 subside, as is shown by the decrease in the tension 
 of the joint, gentle passive movement (flexion and 
 extension) is commenced, and if upon the commence- 
 ment of the passive movement no increase of effusion 
 occurs, the splint is put aside altogether. When the 
 patient comes under treatment immediately after the 
 
DETAILS OF METHOD 61 
 
 injury the splint can generally be dispensed with on 
 the third day. With the discarding of the splint 
 gentle massage of the thigh and leg is added to the 
 rubbing of the joint itself, the passive movement and 
 the massage becoming more and more thorough as 
 the effusion subsides. A compress of the kind men- 
 tioned may be used in the intervals if it is comfort- 
 able to the patient. Treated in this simple way there 
 are few cases of severe sprain of the knee in which 
 the patient may not be getting about comfortably 
 in a fortnight, at the end of which time another 
 fortnight of methodical exercises, either in a gymna- 
 sium or by means of a l home ' exerciser, will generally 
 complete the cure. I have taken as an example 
 a severe case requiring confinement to bed. The 
 treatment of the milder forms is modified to the 
 necessities of the case, the great points to be borne 
 in mind being the necessity for avoidance of the use 
 of splints after the effusion has commenced to subside, 
 the immediate use of massage to the joint, and early 
 passive movement. In all cases the early movement 
 should be passive the habit of sending the milder 
 forms of sprains at once to the gymnasium is to 
 be avoided. In no case of sprain should a cure 
 be considered to have been obtained if any sign of 
 wasting of muscle beyond that which comes from 
 mere disuse remains. The longer the time which 
 intervenes between the receipt of the injury and the 
 commencement of the rational treatment the greater 
 
62 MASSAGE AND MOVEMENTS IN SPRAINS 
 
 is the difficulty in rectifying the muscle-waste with 
 its necessarily concurrent weakness, and in cases 
 in which the parts have been long confined in splints 
 a cure in the true sense is sometimes impossible. 
 
 The following points in the carrying out of passive 
 movement in cases of sprain are of some moment. 
 The first movement used should be those of the 
 simplest kind ; for example, flexion and extension 
 in the hip or knee, antero-posterior movement in 
 the shoulder ; abduction and adduction should then 
 follow, and finally rotation and circumduction in 
 joints permitting of that movement. This sequence, 
 however, is always interrupted for the following 
 reason, which is of paramount importance : the last 
 movement to be practised should be that which, so far as 
 can be ascertained, was concerned in the production of 
 the injury. Let me make myself clear. Suppose for 
 a moment that a severe sprain of the shoulder has 
 been caused by a fall on the hand or elbow, the arm 
 having been at the time widely abducted from the 
 side ; the damage will be probably about the inner 
 aspect of the capsule or under the acromion. In such 
 a case passive abduction should be the last movement 
 practised, as it would be the movement most likely 
 to irritate the part immediately lacerated or bruised. 
 Although it should be the last movement to be 
 commenced it should not, however, be long deferred, 
 seven days being probably the limit of time which 
 can with safety be spared before its commencement. 
 
OBJECT IN ADVOCATING THE METHOD 63 
 
 Again, in the sprain occurring in internal derange- 
 ment of the knee-joint the injury is almost always 
 caused by either internal or external rotation. In 
 such a case, therefore, the last movement to be prac- 
 tised is rotation. Indeed, it is, speaking generally, 
 better to avoid rotation altogether in that particular 
 class of case. 
 
 In sprains complicated by external wound it is 
 clear that the plan which I have been advocating 
 cannot immediately be adopted in its entirety, nor 
 can massage be comfortably practised directly over 
 the damaged part when the skin is abraded or raw ; 
 but in such circumstances massage of neighbouring 
 muscles and passive movement should always be 
 practised, the peculiarities of each case dictating 
 the modifications which are necessary in the applica- 
 tion of the treatment. 
 
 I had intended giving some details of the treat- 
 ment of simple bruises by the same plan of massage 
 and movement, but the allotted time has been more 
 than spent. All, therefore, that I can say is that in 
 these cases the method of its application and the 
 objects are the same as those already mentioned 
 viz. the rapid removal of effusion and the prevention 
 of matting of the injured parts. 
 
 In conclusion allow me to say that I have no 
 desire that the treatment which I have been now 
 advocating should be used to the exclusion of all 
 others. My main object is to urge upon you the 
 
64 AMBULATORY TREATMENT OF FRACTURES 
 
 desirability of shaking of! to some extent the incubus 
 of the traditional routine treatment of fractures and 
 the other kinds of injury of which I have been 
 speaking by prolonged splinting, strapping, counter- 
 irritants, and so forth, and, unless unavoidable cir- 
 cumstances prevent, to substitute a line of treatment 
 which is, I am sure, rational, and will in the end be 
 found by anyone who will take the trouble to acquire 
 a personal experience of it, to produce in a general 
 way results far superior to those obtainable by other 
 plans. 
 
 THE AMBULATORY TREATMENT OF FRACTURES. 
 
 This may be regarded as a modification of the 
 method of treatment by massage and early move- 
 ments ; it is, therefore, conveniently referred to here. 
 
 The main principle of the treatment is the appli- 
 cation of some form of instrument or immobilisation 
 apparatus by which the fragments are retained in 
 position in such a way that the upright position 
 may be assumed during the healing of the break, the 
 patient being allowed very early in the course of 
 the treatment to bear weight upon the limb. It is a 
 method which has not made any great progress in this 
 country, partly, I fancy, because of the expense 
 entailed in sometimes obtaining the adequate appara- 
 tus, although the main object is partly attained 
 by those who adopt the immediate use of plaster of 
 
Plate V. 
 
 Ernst's Instrument for Ambulatory treatment in slow or delayed union 
 in fracture of the thigh. 
 
AMBULATORY TREATMENT OF FRACTURES 65 
 
 Paris and other similar means of immobilisation in 
 fracture of the legs, a region to which this mode of 
 treatment must be for the most part limited in con- 
 sequence of the difficulty of obtaining an efficient 
 apparatus or arrangement in cases of fracture of the 
 hip and thigh. 
 
 Although such arrangements may be obtainable 
 in specially favourable circumstances, it is obvious 
 that for the ordinary practitioner the method can 
 hardly come within the limits of practical work, at 
 all events so far as recent fractures are concerned. 
 
 In delayed or soft union, however, the matter 
 is different ; in such cases there is, in my experience, 
 no more efficient plan, short of operation, of bringing 
 about a proper union than fitting the limb with a 
 skilfully made apparatus which, whilst it prevents 
 undue pressure between the fragments and bending 
 of the parts at the seat of fracture, allows a patient 
 to walk about with or without the aid of a stick or 
 crutch. Plate V shows an efficient apparatus adapted 
 to a case of delayed union in a fractured femur, 
 and Mr. Ernst has contrived for me an admirable 
 high boot containing concealed steel supports with a 
 joint at the ankle which has given truly excellent 
 results in similar conditions of the leg. It is more- 
 over the best means with which I am acquainted 
 of getting a patient rapidly on his legs after an 
 ordinary fracture of the tibia or fibula. 
 
 F 
 
66 SPRAINS AND THEIR CONSEQUENCES 
 
 LECTURE III 
 
 SPRAINS AND THEIR CONSEQUENCES, MAINLY IN 
 RELATION TO TREATMENT. 
 
 THE commonly-reckoned ' little things ' of surgery 
 are, it must be admitted, not popular with surgeons 
 generally at the present time, when the great achieve- 
 ments of operative work are apt to overshadow so 
 completely the treatment of minor ailments, that they 
 are frequently relegated to the category of cases 
 too uninteresting to call for much attention at the 
 hands of those who are mostly concerned in dealing 
 with matters which are apparently more important. 
 Unless, therefore, I had been asked to do so, I should 
 not have presumed to contribute to the ' British 
 Medical Journal ' an article upon such a trivial 
 subject as sprains. 1 It is, nevertheless, probable 
 that the neglect or indifferent treatment of some of 
 these minor matters results in more disability among 
 the community generally, especially the wage-earn- 
 ing classes, than would arise from a considerable 
 percentage of the cases which are considered to 
 
 1 December 8, 1906. 
 
CLASSIFICATION OF SPRAINS 67 
 
 require operation if they were left alone ; and, fur- 
 ther, it is undeniable that, if the minor things were 
 always adequately treated at their commencement 
 or when they threatened, operations would be less 
 frequently necessary. 
 
 DEFINITION AND CLASSIFICATION OF SPRAINS. 
 
 A reference to the latest textbooks will give but 
 scanty information on these points ; indeed, except- 
 ing sprains of joints, little mention is made of 
 them. 
 
 A few years ago the definition of a sprain was 
 ' a wrench or strain resulting in stretching or lacera- 
 tion of the soft parts, without external wound. ' 
 Academically this definition may still be regarded 
 as sound, but for working purposes it has been conclu- 
 sively shown by the x-rays that sprains commonly 
 so called are in quite a large proportion of cases 
 complicated by slight fractures, a very important 
 point in relation to treatment. In fact, under the 
 usual nomenclature a good percentage of sprains 
 should be classified as fractures. The fracture, how- 
 ever, in these cases is of subordinate importance 
 in a pathological sense, because the sprain of the 
 soft parts is the predominating feature. A fracture 
 can hardly occur without a sprain at the same time, 
 but a sprain may of course, and frequently does, 
 
 72 
 
68 SPRAINS AND THEIR CONSEQUENCES 
 
 occur without a fracture. For my own convenience 
 I am in the habit of classifying sprains as follows : 
 
 1. Simple sprains involving the soft parts only. 
 
 2. Sprains with fracture, by which I mean a sprain 
 complicated by a fracture, the symptoms of which 
 are so slight as to make it undiagnosable under 
 ordinary circumstances, the symptoms of sprain being 
 altogether predominant. 
 
 3. Sprains with gross nerve injury. 
 
 For clinical purposes this classification will be 
 found not only reasonable but useful. Speaking 
 generally, then, a sprain may be considered as a 
 subcutaneous laceration ; at the same time, it must 
 be allowed that certain parts may be susceptible of 
 stretching, without actual tearing, to a degree that 
 will cause great pain. Hence, for working purposes, 
 sprains may be divided into those associated with 
 swelling and those followed by pain and stiffness 
 only, the latter condition being formerly spoken of as 
 ' strain/ 
 
 Immediate swelling means, of course, blood 
 extravasation or the contraction of the proximal 
 portion of extensively ruptured muscle ; deferred 
 swelling in the immediate region of the injury being 
 due to inflammatory exudation into the soft parts 
 in the continuity of a limb or about the trunk, or, 
 in the case of a joint, synovial effusion. 
 
 In relation to the question of swelling, it must be 
 
DIAGNOSIS AND TREATMENT 69 
 
 borne in mind that the possibility of denning it is 
 in direct proportion to its nearness to the surface 
 of the part. A swelling from extravasation on the 
 deep surface of the erector spinse would be quite 
 intangible, whilst in the quadra tus femoris it would 
 be easily felt ; moreover, it must be remembered 
 that deferred or remote swelling in deep sprain may 
 show itself a long way from the seat of the original 
 injury, in consequence of its being caused by the blood 
 tracking along the fascial planes in the line of least 
 resistance. I have, for example, recently seen a 
 large heematoma below the buttock show itself a 
 week after a severe sprain of the erector spinse whilst 
 fencing, and I have seen a large blood tumour appear 
 in the popliteal space many days after a sprain of the 
 upper part of the thigh. 
 
 DIAGNOSIS AND TREATMENT. 
 
 The first essential in all cases of sprain is to de- 
 termine whether fracture co-exists, which can readily 
 be done by the x-rays when they are available ; 
 it should, indeed, be an accepted practice that, 
 when possible, every sprain, especially those near 
 joints, should be examined by the x-rays. In the 
 event of the x-rays being unobtainable, it is wise 
 to regard any case in which the symptoms of 
 sprain near a joint are unduly exaggerated as being 
 
70 SPRAINS AND THEIR CONSEQUENCES 
 
 complicated by fracture, especially if the parts con- 
 cerned be the phalanges of the fingers or the meta- 
 carpal region. Plates VI, VII and VIII are from x-ray 
 photographs of cases of so-called sprain in which 
 the bone lesion had been undetected until revealed 
 by the x-rays some time after the injuries had 
 occurred. 
 
 The frequent overlooking of bone lesions in so- 
 called sprains seems to be greatly due to the fixed 
 idea on the part of many people that crepitus is a 
 necessary symptom of fracture, and that absence of 
 crepitus means absence of fracture : a sadly mistaken 
 belief, inasmuch as, it need hardly be said, fracture 
 often occurs in circumstances in which the detection 
 of crepitus is impossible. On the other hand, crepitus 
 after injury, especially if near a joint, may be elicited 
 when no fracture is present. I have seen several 
 cases of injury near joints in which fracture has been 
 either diagnosed or strongly suspected on the strength 
 of crepitus resulting from osteo-arthritis in the 
 adjacent articulation. 
 
 The next desideratum is to eliminate the existence 
 of gross nerve lesion. Speaking generally, the pain 
 in cases of sprain is referred to the seat of injury. 
 Should it be referred to a distant part, to the side 
 of the foot, for example, in a case of sprain of the 
 knee, definite nerve lesion is indicated. In all cases 
 of sprain, especially of the knee, elbow and shoulder 
 
Plate VI. 
 
 ! pi! 
 HI! 
 
DIAGNOSIS AND TREATMENT 71 
 
 regions, the distal parts should be examined for 
 numbness, a much commoner condition than it is 
 usually supposed to be, and one which is frequently, 
 when it does exist, at first unnoticed by the patient. 
 This numbness, which may be exceedingly limited in 
 area, if due merely to nerve shock disappears in a 
 few hours ; if, however, it persists for more than 
 twelve hours a gross lesion of the nerve branch 
 concerned is pretty certain. 
 
 Simple Sprains. Setting aside cases complicated 
 by fracture on the one hand and by nervous lesion 
 on the other, sprains may be, for purposes of treat- 
 ment, divided into two classes those with swelling 
 and those without, the latter being a very small 
 minority, which is practically limited to sprains 
 about joints and amongst the deep muscles of the 
 back and neck. 
 
 Sprains without swelling (formerly called 'Strains'). 
 Here the main immediate indication is the relief 
 of pain, which in these cases is frequently intense. 
 Eest of the part, combined with very firm compres- 
 sion of the region immediately concerned, is usually 
 effectual in this respect if the pressure is of the right 
 kind ; and I know of no means of applying effectual 
 pressure excepting strapping, which should, if ob- 
 tainable, be to a certain extent resilient, like, for 
 example, the wash-leather strapping made by Messrs. 
 Ewen & Son, which is ideal for this purpose. It is, 
 
72 SPRAINS AND THEIR CONSEQUENCES 
 
 however, perhaps too expensive for ordinary use, 
 the best alternative being Leucoplast, which, although 
 made in Germany, is in my experience so far superior 
 to the English varieties of the same thing that my 
 patriotism does not prevent my using it. (It should 
 be borne in mind that the real object of the use of 
 strapping in these cases is to give support, and 
 hence rest, to the part ; its proper application is 
 therefore a matter of some moment, especially in 
 parts constantly moving, like, for instance, the chest 
 wall. In sprain of one side of the chest the strap- 
 ping should, of course, be made to include at least 
 two-thirds of the circumference of the thorax, passing 
 well beyond the middle line in front and behind, the 
 application of each strip being made quickly at the 
 end of a complete expiratory effort. An apology is 
 needful for these elementary details, but my experience 
 shows that some little facts of this kind are not 
 familiar to us all.) The immediate pain having been 
 thus relieved, massage cannot commence too soon ; 
 but passive movement in these cases is better deferred 
 for six or seven days, as secondary swelling is apt 
 to follow its use if employed too soon. Voluntary 
 movements by the patient may. however, be allowed 
 from the first, the extent of these movements being 
 determined by the amount of pain : as a matter 
 of fact, in many of these cases, as well as in some 
 other varieties of sprain, voluntary movements by 
 
DIAGNOSIS AND TREATMENT 73 
 
 the patient are frequently a source of immediate 
 comfort. 
 
 Sprains with Immediate Swelling (from Blood). 
 The classical indications here are threefold : (a) Arrest 
 of bleeding ; (b) promotion of absorption of extra- 
 vasated material ; (c) prevention of adhesions and 
 muscle-waste. 
 
 (a) With regard to the first indication, I do not 
 think local treatment other than rest has any material 
 effect. I have rarely seen the application of ice 
 do anything but harm, although in an occasional 
 case the instinct of the patient may lead to its being 
 suggested. At all events, it is wise, if its applica- 
 tion should be decided upon, to ascertain, especially 
 in middle age and later, whether the kidneys are 
 sound, for I have seen three cases in which extensive 
 sloughing followed the continued application of ice 
 in sprains with swelling in confirmed albuminuria, no 
 precaution having been taken before the adoption 
 of the treatment to inquire as to the possibility of 
 renal disease : an excellent example of the way in 
 which the apparently trivial nature of a case may 
 lead to careless treatment of it. So far as the com- 
 fort of the patient is concerned, a fomentation, the 
 hotter the better, has served my purpose best. 
 Pressure during the increase of immediate swelling 
 I do not use; it is as often as not distressing to 
 the patient, and frequently produces oedema of the 
 
74 SPRAINS AND THEIR CONSEQUENCES 
 
 tissues below, if the part concerned is a limb. To 
 sum up, rest of the part with very hot fomentations 
 are the means I have come to rely upon. 
 
 (b) The increase of the immediate swelling hav- 
 ing ceased, should the part involved be a joint, firm 
 pressure by means of a porous bandage, such as 
 crepe velpeau, firmly and evenly applied for twenty- 
 four hours, followed by massage, gives the best and 
 quickest results. The use of impermeable rubber 
 bandages I have long since given up. Should 
 massage not be available, skilfully-applied strapping 
 is the best alternative, the frequency of its renewal 
 being determined by the rate of diminution in the 
 swelling. If the sprain be of the soft parts without 
 joint complication, hot soothing compresses, such 
 as the old and well-tried lot. plumbi cum opio, fre- 
 quently changed, are more helpful than any other 
 means, so far as I have seen, the pressure being 
 increased as the swelling subsides. As soon as ap- 
 preciable diminution in the swelling has occurred 
 massage is indicated unless the part is abnormally 
 hot to the touch. 
 
 (c) For the prevention of adhesions and muscle- 
 waste, voluntary movements, massage, and passive 
 movements rank in the order mentioned. Slight 
 voluntary movements cannot be commenced too 
 soon ; splints, therefore, should in a general way 
 not be used. The patient should, in fact, from the 
 
DIAGNOSIS AND TREATMENT 75 
 
 earliest moment amuse himself by seeing how far 
 the part, if a joint, can be bent without permanent 
 increase of discomfort. Massage should not, except 
 in special circumstances, be delayed for more than 
 twenty-four or at the most thirty-six hours after the 
 cessation of increase in the local swelling. Passive 
 movements should follow freely as soon as all heat 
 has left the damaged part, whether the swelling be 
 tense or not ; and if the tension be rapidly diminish- 
 ing gently passive movement may be used in spite of 
 slight local increase of heat ; but if the increase of 
 the heat, which under these circumstances is sure 
 to follow, does not subside within an hour or two, 
 passive movement should be deferred for a time, 
 although voluntary movements may be continued. 
 
 When an interval occurs between the receipt 
 of the injury and the oncoming of the swelling, and 
 in cases in which swelling, having followed directly 
 after the injury, reappears after it has entirely dis- 
 appeared or nearly so, the line of treatment mainly 
 depends (1) upon the absence or presence of heat, 
 and (2) in the case of joints upon the amount of 
 tension. 
 
 In the absence of local heat, free massage and 
 manipulation are indicated, combined with firm 
 elastic (not rubber) pressure. In effusion without 
 heat occurring in joints a fortnight or more after 
 the accident, the possibility of syphilis or gout as 
 
76 SPRAINS AND THEIR CONSEQUENCES 
 
 contributing factors must not be overlooked. Iodides 
 in some form internally are often helpful, especially 
 when combined with free inunction of vasogen 
 iodine locally. I know of no application which 
 ensures the local effects of iodine without irritation 
 to the same extent as this. 
 
 In well-marked hsematoma in easily accessible 
 soft parts coming on immediately after sprain, the 
 course of the case may be greatly shortened by free 
 incision and cleaning out of all clots, followed by 
 immediate suture of the wound. 
 
 Tension in Joints after Sprains. This may be 
 immediate or secondary, that is, occurring after an 
 interval varying from two or three days to a week. 
 When occurring later than this it may be regarded 
 as due either to a repetition of injury, or to some con- 
 stitutional cause for example, syphilis, rheumatism, 
 gout, septicaemia, &c. 
 
 Tension is always associated with local heat, 
 although in some cases this is very slight ; the more 
 quickly a high degree of tension follows the injury 
 the greater is the heat ; the same may be said of 
 the pain, which, in immediate tension, is sometimes 
 of great intensity. Hence it is the pain from which 
 relief is sought. Rest, of course, is essential, and if 
 this, aided by very hot fomentation, fails to give 
 comfort, direct relief by means of the aspirator is 
 the indication. This in the hands of a competent 
 
DIAGNOSIS AND TREATMENT 77 
 
 practitioner who understands the value of cleanliness 
 is not only more effectual than the alternative usually 
 recommended, namely, leeches, but is also, I think, 
 safer. I have seen no harm follow aspiration, which 
 I cannot say in the case of leeches. The withdrawal 
 of only a sufficient amount of the bloody fluid to 
 relieve the tension should be made, as this is less 
 likely to be followed by a recurrence than when 
 as much fluid as possible has been drawn off. The 
 tendency to recurrent tension in cases of this kind 
 is also, I have reason to believe, diminished by the 
 administration internally of calcium chloride. In 
 the case of tension coming on after an interval, on the 
 other hand, if relief by aspiration becomes necessary, 
 as much fluid (synovia) should be removed as possible, 
 and firm pressure immediately applied. After the 
 relief of tension, the use of massage and movement, 
 voluntary and passive, will be regulated entirely by 
 the behaviour of the local temperature of the part, 
 to which reference has already been made. 
 
 Sprains with Fracture. The treatment of these 
 injuries differs only from that of simple sprains in the 
 following particulars : Although massage may be, 
 and as a rule should be, commenced at once, rest for 
 the part in splints of some kind must be maintained 
 for a long enough period to enable the detached 
 piece of bone to reunite sufficiently to retain its posi- 
 tion during voluntary movements. Hence, as early 
 
78 SPRAINS AND THEIR CONSEQUENCES 
 
 movements are essential to quick recovery, these 
 must be passive, and not voluntary, as in simple 
 sprain. This is a most important point in the treat- 
 ment in these cases, especially in connection with 
 deformities following sprains a matter with which 
 I shall deal presently. The treatment of simple 
 sprains may be tabulated thus : (1) Voluntary 
 movement, (2) massage, (3) passive movement and 
 exercises ; whilst that of sprains with fracture would 
 run : Massage, passive movement, voluntary move- 
 ment and exercises ; the reason for the early use of 
 passive rather than voluntary movements being 
 obviously that the detached piece of bone is not dis- 
 turbed during the use of passive movement if properly 
 carried out ; whereas, if voluntary movement were 
 allowed, imperfect or faulty union would not im- 
 probably follow with the usual imperfect recovery. 
 
 These remarks apply only to cases in which there 
 is a definite detachment of a portion of bone ; they 
 have no bearing upon cases of so-called ' sprain- 
 fractures ' in joints in which the cartilage is in part 
 torn from the articular surface, the bone being 
 involved in the lesion. The treatment of such cases, 
 which are generally undiagnosed if they often occur, 
 differs in no respect from that of simple sprains. 
 
 Sprains with Gross Nerve Injury. Of all cases 
 of sprain, these are in some respects the most impor- 
 tant, because of the difficulty in their treatment and 
 
Plate VII. 
 
 FIG. I. 
 
 FIG. II. 
 
 FIG. I.' Motor sprain ' of wrist. Separation of styloid process of radius, 
 caused by attempt at starting the engine of a motor car. Fracture 
 discovered by use of x-rays some time after the injury. 
 
 FIG. II. 'Motor sprain.' Comminuted fracture of lower end of radius, 
 caused in the same way as fig. I. There was no deformity; the 
 fracture had not been detected until shown by as-rays three months 
 after the injury. 
 
DIAGNOSIS AND TREATMENT 79 
 
 the resulting imperfect cure which so commonly 
 follows, although it must be admitted that the 
 defective recovery is not generally attributed to its 
 real cause. As is the case with sprains with fracture, 
 many of the imperfect results are due to indifferent 
 diagnosis, the nerve lesion having escaped notice in 
 consequence of the slightness of its symptoms at the 
 time of injury. Hence, as I have already said, the 
 importance of a definite search for evidence of nerve 
 damage in cases of sprain cannot be over-emphasised. 
 In the treatment of these cases, when the evidence 
 of nerve lesion is pain along the line of distribution of 
 the nerve, rest and rest only will bring about a com- 
 plete and permanent cure. This rest, if it is to be 
 successful, must be continued until all symptoms 
 of nerve pain have passed away. Herein lies the 
 difficulty in treatment, for it is next to impossible 
 to induce some patients to realise the importance 
 of resting the part concerned long enough to ensure 
 immunity from the persistent pain which is prone to 
 follow in these cases. Massage does nothing but 
 harm in the early stages of this type of case, but if 
 the condition becomes chronic from neglect of treat- 
 ment in the early stages, it may be of use, especially 
 if associated with static electricity ; and the exacer- 
 bation of pain in chronic cases is frequently greatly 
 relieved by the repeated application of the fine point 
 of the thermocautery along the line of pain. 
 
80 SPRAINS AND THEIR CONSEQUENCES 
 
 In cases where numbness is the indication of nerve 
 lesion the treatment is altogether different, for if 
 this symptom has not disappeared in 24 hours the 
 only hope of cure lies in the skilful use of massage 
 supplemented after two or three days by galvanism. 
 If the affected part be a limb, exercise should be 
 encouraged, and in any part flying blisters over the 
 seat of the lesion may be safely used, since in a certain 
 number of cases they do good, and in none does harm 
 arise from their employment. It is singular how 
 readily areas of numbness may sometimes escape 
 the notice of both surgeon and patient. In a case 
 which came under my observation a patient having 
 ' sprained ' his leg was entirely unaware of any loss 
 of sensation in the foot until, in attempting to get 
 some warmth into the part, he found he was charring 
 his toe by unconsciously holding it in contact with 
 the bar of the grate. 
 
 EEMOTE CONSEQUENCES OF SPRAINS. 
 
 The later consequences of sprains may be tabu- 
 lated in the following way : 
 
 Persistent pain. 
 Stiff joints. 
 
 Wasting of muscles (apart from 
 Preventable . . ( . . . 
 
 | gross nerve lesion). 
 
 General relaxation of joints. 
 Deformity. 
 
Plate VIII 
 
 Impacted fracture of the malleolar end of the fibula, frequently 
 diagnosed as 'sprain,' the cardinal signs of fracture being absent. 
 It is believed that this impacted fracture has not hitherto been 
 described. 
 
PREVENTABLE CONSEQUENCES 81 
 
 Unavoidable f Osteo-arthritis. 
 
 in j Local paresis, 
 
 certain cases. 1 Myositis ossificans. 
 
 PREVENTABLE CONSEQUENCES OF SPRAINS. 
 
 Persistent Pain. This condition is usually caused 
 by excessive immobilisation in ordinary cases giving 
 rise to adhesions and matting of the parts, but it 
 may be due to too early movements in cases asso- 
 ciated with nerve lesion. Speaking generally it 
 may be said that in simple sprains the discriminating 
 use of massage and movement cannot be commenced 
 too soon after the immediate effusion has ceased to 
 increase ; on the other hand, if nerve lesion with 
 pain exists, rest is essential until the pain has passed 
 away. 
 
 Stiff Joints. Stiffness of joints after sprains 
 is almost always due to the prolonged use of splints 
 or delay in the commencement of voluntary and 
 passive movements. Stiffness of this kind can be 
 nearly always avoided by the removal of splints, 
 if their use is considered necessary, once daily for 
 an hour or so, during which the patient is encouraged 
 to move the part as much as the pain will allow. 
 It appears that one of the main reasons for the 
 prolonged use of splints in sprains of joints is the 
 
 fear of tubercle, but in the absence of persistent local 
 
 G 
 
82 SPRAINS AND THEIR CONSEQUENCES 
 
 heat it is hardly needful to say that the fear of 
 tubercle is entirely unnecessary. 
 
 Recently I have seen a case in which, in conse- 
 quence of acute effusion into the knee-joint after 
 sprain, the part was immobilised in splints for six 
 months, with the result that a bony ankylosis fol- 
 lowed. Nothing can be more harmful in sprain of 
 joints than the too prolonged use of splints. Person- 
 ally, in sprains the existence of fracture having 
 been excluded by the use of the x-rays I have long 
 since given up the use of splints altogether. 
 
 General Relaxation of Joints. This, the exact 
 reverse of the condition just referred to, may, in 
 the absence of very extensive laceration of the cap- 
 sule, &c., for practical purposes be considered to 
 be due to wasting of muscles on the proximal side 
 of the articulation, the knee for many reasons being 
 the joint mainly concerned. Wasting of the muscles 
 of the thigh invariably leads to laxness of the capsule 
 of the knee-joint, and the bagginess of the capsule 
 thus resulting means passive effusion, a fact which 
 does not seem to be familiar to some people. The 
 resulting fulness of the joint, especially when the 
 patient stands, leads the inexperienced to devote 
 the entire attention to the ' fluid in the joint/ with 
 the result that one of two extremes in the way of 
 treatment is adopted (1) prolonged use of splints, 
 or (2) vigorous methods confined to the joint itself 
 
PREVENTABLE CONSEQUENCES 83 
 
 for example, blisters, actual cautery, strapping, 
 &c., the result being almost invariably a ' wobbly ' 
 joint. 
 
 If, in cases of this kind, it were generally recog- 
 nised that the primary factor of importance is the 
 muscle- waste, the condition of the joint being secon- 
 dary, the number of lax joints would be very small, 
 because, with very few exceptions, the condition 
 follows only in cases improperly treated. If voluntary 
 movements be commenced sufficiently early, whilst 
 the patient is resting, and are aided by massage, 
 and later on by passive movements plus resistance 
 exercises, muscle-waste will be entirely avoided, unless 
 the injury has caused gross tearing of muscles, 
 especially at their aponeurotic or tendinous attach- 
 ments ; for example, the muscle-waste in ' rider's 
 sprain ' (laceration of the tendon of origin of the 
 adductor longus in the thigh) is rarely, if ever, so far 
 as I have seen it, completely repaired. 
 
 Deformity. This is in some respects the most 
 interesting of the remote preventable results of 
 ' sprains ' so-called. These deformities are met with 
 most commonly in the fingers, but are also seen in 
 the knee, in the form of genu valgum principally ; 
 in the hip, and at the wrist and ankle. In adults 
 they are virtually always the result of undetected 
 fracture ; in growing people they may arise from 
 injuries to the epiphyses, but even in these subjects 
 
 02 
 
84 SPRAINS AND THEIR CONSEQUENCES 
 
 undetected fracture is the commonest cause. 1 Sprain 
 of an epiphysis may cause arrest of development 
 or irregular growth, the best example of the latter 
 condition being certain cases of genu valgum. 
 
 Fig. 12 is a diagram showing the mechanism of 
 a characteristic case of deformity of a finger following 
 ' sprain/ There has been an oblique fracture of the 
 
 FIG. 12 
 
 Diagram illustrating the mechanism of deformity following upon undetect 
 fracture of base of phalanx of finger. 
 
 base of one of the phalanges ; the fracture having 
 been undetected, no means were taken to secure 
 adhesion of the separated part during the use of 
 
 1 In three cases of ' motor sprain ' in young subjects which came 
 under notice the arrays showed separation of the lower epiphysis of 
 the radius. 
 
PREVENTABLE CONSEQUENCES 85 
 
 massage, &c. The result is that the fragment has 
 glided upwards in such a way as to cause the distal 
 part of the finger to fall over in an angular deformity. 
 
 Plate VI A shows a skiagram of a case of a very 
 exaggerated kind in which the same distortion is 
 in course of occurrence. Such deformities of the 
 fingers after sprains are not unfrequently attributed 
 to osteo-arthritis ; genu valgum and genu varum 
 may arise in the same way. The following is a 
 typical example. 
 
 A young man, twenty-two years old, strong and 
 healthy, consulted me on account of genu valgum 
 of an exaggerated kind, which was said to have 
 come on rather rapidly during the convalescence from 
 a severe sprain of the knee. An x-ray photograph 
 clearly showed that the external condyle had been 
 detached by an oblique fracture and had glided up- 
 wards, so that when* attempts at walking were made 
 the leg necessarily bent outwards from the knee. 
 
 A few years ago ' sprains ' of the hip were spoken 
 of as being sometimes followed by shortening of the 
 limb from a mysterious change in the bone, which 
 was thought to bring about an alteration in the angle 
 at which the neck of the femur left the shaft. The 
 x-rays have abundantly shown that the common 
 cause of this deformity is undetected fracture of the 
 neck of the thigh-bone, and in a few cases perhaps 
 injury to the epiphyses in growing subjects. 
 
86 SPRAINS AND THEIR CONSEQUENCES 
 
 It is a singular thing that there is even now a 
 disinclination upon the part of some people to utilise 
 the x-rays in cases of sprain. Recently an instance 
 has come to my knowledge in which a practitioner 
 of large experience and repute advised against the 
 use of the x-rays on the grounds that they would 
 merely corroborate his diagnosis in a case of ' sprain ' 
 of one of the larger joints. Symptoms having sub- 
 sequently arisen which were hardly consistent with 
 a mere sprain, however severe, the x-rays were 
 employed, upon the recommendation of another 
 authority, with the result that a very manifest 
 fracture was revealed. 
 
 An attitude of this kind towards a means of 
 diagnosis which in competent hands can set at rest 
 once and for all any question as to fracture with 
 absolute certainty passes the comprehension of a 
 person of only ordinary intelligence. 
 
 UNAVOIDABLE CONSEQUENCES OF SPRAINS. 
 
 Osteo-arthritis. The relation of osteo-arthritis to 
 injury cannot be said to be much understood ; it 
 is, however, quite certain that its first manifestation 
 frequently follows upon some comparatively slight 
 injury to a joint, especially if this is followed by 
 effusion. The subject generally is too large for dis- 
 cussion here, but it is, I think, undeniable, if my own 
 
UNAVOIDABLE CONSEQUENCES 87 
 
 experience is of any value, that excessive immobili- 
 sation of joints after injury tends to the development 
 of this condition. In other words, the chances of 
 osteo-arthritis developing after injury is much greater 
 when unnecessary rest has been used than when, 
 by massage and rational movements, the parts have 
 been kept supple from the commencement. 
 
 Local Paresis. Gross nerve lesion may, of course, 
 result in permanent loss of power, in spite of the most 
 skilful treatment ; but it is often of much moment 
 that the practitioner should be able to warn a patient 
 of the possibility of results of this kind ; hence, as 
 has been already indicated, the desirability of ascer- 
 taining immediately after the injury whether nerve 
 complication does or does not exist is a matter of 
 some urgency. 
 
 Traumatic Myositis Ossificans. This is, perhaps, 
 the rarest, and at the same time the most interesting 
 of the remote consequences of sprains. Sprains 
 of muscles, involving as they may do the points of 
 attachment to the bone, may be followed, especially 
 in the case of the quadratus femoris, by gradual 
 ossification, completely or in part. The process is 
 slow and little, if at all, painful, such pain as may be 
 felt being of the nature of a dull aching or feeling of 
 weight. The joint controlled by the ossifying muscle 
 becomes increasingly restricted in its movements. 
 For example, in myositis ossificans of the quadratiis 
 
88 SPRAINS AND THEIR CONSEQUENCES 
 
 femoris flexion at the knee becomes slowly less and 
 less, although it is rarely that flexion to a right angle 
 cannot be ultimately accomplished. The muscles 
 involved become hard and seem to be exaggerated 
 in size ; there is little or no tenderness, but the 
 limb becomes more and more heavy as the disease 
 goes on. The liability to this condition seems to 
 be too little understood. 
 
 Plate IX is a skiagram of a portion of the thigh 
 of a woman about 24 years of age, by whom I was 
 consulted in consequence of amputation having been 
 advised on account of sarcoma. In another case 
 which came under my notice amputation had been 
 suggested by a very experienced surgeon on the 
 same grounds. Again, within the last six months a 
 naval officer was referred to me on account of a 
 large mass involving the middle of the thigh after 
 an injury, which had been regarded as malignant 
 disease. In this case as in the others with which 
 I have met, the arrays showed superimposed layers 
 of calcification arranged in accordance with the 
 muscle structure as shown in Plate IX. 
 
 With regard to the treatment of this condition 
 it seems certain that, once it has actually commenced, 
 rest is essential until it has ceased to increase ; 
 massage and movements, passive or voluntary, 
 during its progress, undoubtedly stimulate it to 
 increase. Operation in some of these cases has been 
 
Plate IX. 
 
 3 o 
 
 tc'S 
 
UNAVOIDABLE CONSEQUENCES 89 
 
 adopted, masses of bone-like material having been 
 removed, but unless the periosteum with which some 
 of these masses are connected is also completely 
 removed, regrowth with increased vigour follows. 
 Operation is, in fact, generally harmful, and should 
 be rejected. Rest having been used until the ten- 
 dency to increase in the condition has ceased, mas- 
 sage and exercise should follow, with a view to obtain- 
 ing as much usefulness as possible in such portions 
 of the muscle as have remained intact. The altera- 
 tion in the bulk of the muscle remains permanently, 
 the normal state is never recovered. The compara- 
 tive painlessness of the condition should make it 
 difficult to confuse it with periostitis, the lesion for 
 which it is generally mistaken. 
 
 Plate X shows traumatic myositis ossificans 
 after a sprain of the elbow the possibility of fracture 
 having been originally eliminated by the x-rays. 
 Massage and exercise were tried in this case, with 
 the result of steadily increasing the bulk of the mass ; 
 subsequently complete rest for six months caused a 
 diminution to about one-half of the previous size. 
 
 The relation of tuberculosis of joints and of tendon 
 sheath to sprain is of much interest, but its discussion 
 is outside the limits of the present lecture. 
 
90 STIFFNESS OF THE SPINE 
 
 LECTURE IV 
 
 STIFFNESS OF THE SPINE. 
 
 IT is, I presume, hardly needful to say that symptoms 
 are not always in proportion to the gravity of the 
 disease by which they are caused, since it is common 
 knowledge that grave disease may exist without 
 noticeable symptoms, and that distressing symptoms 
 may be associated with comparatively trivial com- 
 plaints. It would be difficult to find a better illus- 
 tration of this fact than that provided by certain cases 
 of rigidity of the spinal column, a condition which, 
 on the one hand, may be a symptom of the greatest 
 moment, and on the other may be of no real import- 
 ance at all provided that an accurate diagnosis of 
 its causation be arrived at. 
 
 The cases included in the following table, which 
 represents only those examples which have come 
 under my personal observation, and is not intended 
 to be a complete list, will show how large a field the 
 question of rigidity of the spine covers, and how 
 many factors are concerned in its production, more, 
 I fancy, than are ordinarily realised : 
 
CAUSES OF STIFFNESS 
 
 91 
 
 TABLE OF CAUSES OF STIFFNESS OF THE SPINE WITH- 
 OUT VISIBLE DEFORMITY, AND EXCLUSIVE OF 
 ACUTE CONDITIONS. 
 
 Tuberculous disease 
 Osteo-arthritis 
 
 Spontaneous AnJcylosis (Sepsis ?) 
 Effects of Empyema 
 Malignant Disease 
 
 PERSISTENT . /J Hydatid of Vertebrae 
 Aneurysm 
 Old Fracture 
 
 Traumatic Myositis Ossificans 
 Congenital peculiarity 
 . Senile rigidity 
 
 Neurosis. N.B. Neuro-mimesis 
 Chronic Rheumatism, Muscular and 
 Fibrous 
 Worms 
 
 Movable Kidney 
 Reflex Renal Calculus 
 Stone in Ureter 
 Hip Disease 
 Early Tuberculosis 
 Gumma 
 
 Sprains and Wrenches 
 Rickets 
 
 INTERMITTENT 
 OR RELAPSING 
 
 TEMPORARY 
 OR TRANSIENT 
 
 NOTE. The lines in italics refer to the less commonly recognised 
 causes of stiffness of the spine, and are those towards which the 
 remarks in the lecture are mainly directed. 
 
92 STIFFNESS OF THE SPINE 
 
 The whole subject is, as can readily be seen, a 
 large one. All that I propose now is to call attention 
 to certain broad features in some of the varieties 
 of spinal stiffness, with a view especially to combat 
 an impression which seems to be far too prevalent, 
 that anything like pronounced rigidity of the spine, 
 in the absence of congenital and acquired deformity, 
 is a strong indication of tuberculous disease an im- 
 pression which I have reason to know too often leads 
 to faulty treatment. 
 
 DISTRIBUTION AND CHARACTER OF STIFFNESS. 
 
 Distribution of the Rigidity. This may involve 
 the whole length of the spine or may be confined 
 to limited areas, e.g., the lumbar, dorsal, or cervical 
 regions separately; in rare cases two distinct areas, 
 e.g., the cervical and dorso-lumbar, may be involved, 
 the intervening parts of the vertebral column retain- 
 ing their suppleness. 
 
 The Characteristics of the Stiffness. (1) The stiff- 
 ness may be absolute that is to say, the spine or 
 the portion of it involved may be rigid like a bar of 
 iron, even when the patient is anaesthetised. (2) The 
 stiffness may be ' sub-absolute ' that is to say, 
 complete in ordinary circumstances, but disappear- 
 ing under the influence of an anaesthetic, the rigidity 
 recurring upon the recovery from the anaesthesia. 
 
PERSISTENT STIFFNESS 93 
 
 (3) The stiffness, although at first apparently abso- 
 lute, becomes, upon proper examination, modified, 
 with the result that the spine begins to ' give ' in a 
 succession of jerks in consequence of the stammer- 
 ing of the muscles a condition which I have ven- 
 turned to call the ' stammering spine/ (4) The 
 stiffness may be, as indicated in the table, persist- 
 ent, intermittent or relapsing, and temporary or 
 transient. 
 
 PERSISTENT STIFFNESS. 
 
 Absolute Rigidity. This may be divided into two 
 varieties, that which is unaffected by the admin- 
 istration of an anaesthetic, and that which disap- 
 pears under anaesthesia. These cases may again 
 be considered under two heads those occurring 
 during adolescence and under the age of twenty- 
 five, and those occurring later in life. In the former, 
 if the rigidity persists under anaesthesia, the cause is 
 probably either tuberculous disease or congenital 
 peculiarity. In tuberculosis other symptoms are 
 generally sufficient to settle the question, but it is a 
 mistake to suppose that the rigidity of tuberculosis 
 is always associated with pain or tenderness, as 
 sometimes both symptoms are wanting. 
 
 It is somewhat surprising that congenital stiffness 
 of the spine, affecting almost invariably the lumbar 
 
94 STIFFNESS OF THE SPINE 
 
 or dorso-lumbar region, is so little recognised, as 
 it is not altogether rare ; the importance of a proper 
 estimate of it is obvious. The following example 
 is sufficient to show this : Whilst a girl eight or nine 
 years old was taking her bath her mother thought 
 that she moved as if her back was stiff, and therefore 
 sought advice of a medical man, who found complete 
 immobility of the vertebrae in the lumbar and lower 
 dorsal region without any deformity. The child 
 seemed perfectly well, had been playing hockey and 
 other games, and showed no signs of any defect. 
 At the same time the rigidity was naturally a cause 
 of anxiety, and the patient was referred to me. 
 Upon examination the lumbar spine was absolutely 
 rigid, there was neither pain, tenderness, nor defor- 
 mity ; in walking there was a slightly peculiar gait, 
 unnoticeable under ordinary circumstances. Having 
 seen cases before of the same kind, notably one 
 recorded in the ' Clinical Journal ' of November 11, 
 1903, I at once suspected the cause of the condition, 
 and, upon examining other members of the family, 
 found the same peculiarity in two of them. The 
 importance of recognising such a condition is clear, 
 as failing such a recognition the temptation to err on 
 the side of safety by treating a case of the kind as 
 one of tuberculosis would be very strong. In a case, 
 therefore, of stiffness of the spine without pain or 
 deformity in a young subject, I never fail to inquire 
 
PERSISTENT STIFFNESS 95 
 
 carefully into the condition of the spines of other 
 members of the family. 
 
 In the absolute stiffness of old people, osteo- 
 arthritis or spontaneous ossification may, in the 
 absence of other distinct indications, be assumed to 
 be the cause, due allowance, of course, being made 
 for the rigidity being possibly due to cured condi- 
 tions (e.g. tubercle) in early life. 
 
 A CHARACTERISTIC CASE. 
 
 In the intermediate period between adolescence 
 and old age a variety of causes such as those 
 enumerated in the table may account for the con- 
 dition, and the clinical symptoms are generally 
 sufficient to prevent any mistake in the diagnosis. 
 The revelation of the x-rays in injury to the cervical 
 spine makes it clear that fracture of the spine, prin- 
 cipally affecting the laminae, but sometimes involving 
 the bodies, ending in recovery, is more common than 
 has hitherto been supposed, and that such cases are 
 followed by stiffness, which varies, of course, accord- 
 ing to the severity and distribution of the injury. 
 I have at the present time a case under observation 
 which illustrates this condition well ; the patient is 
 a man approaching 35 years of age, and the cause was 
 a hunting accident. In persistent stiffness following 
 injury traumatic myositis ossificans must not be 
 
96 STIFFNESS OF THE SPINE 
 
 overlooked as a cause, as although the disease does 
 not, of course, affect the spine itself, the conversion 
 of adjacent muscle into a calcined mass may cause 
 a rigidity as firm as if the spine itself were involved. 
 The following is a characteristic case : A man 35 
 years old slipped downstairs in running to catch a 
 train. Although a good deal shaken, he went about 
 his business at once in the ordinary way, but was 
 unable to resume it on the following day in conse- 
 quence of the pain in his back ' across the kidneys ' 
 he seems to have been laid up for some months, 
 ' on and off/ but finally got sufficiently well to do 
 what was absolutely necessary in the way of getting 
 about his back, however, always remained stiff, 
 bending being difficult and in wet weather painful. 
 For this stiffness he consulted me some three years 
 after the accident, not having previously seen a 
 medical man for about two years. On examina- 
 tion the spine was absolutely stiff over the lumbar 
 region, the dorsal portion being supple. There 
 was no pain, tenderness, or any visible abnormal 
 condition, but on the right side of the lumbar spine, 
 corresponding in outline and situation to the quad- 
 ratus lumborum muscle, over which the erector 
 spinse seemed harder than usual, was a mass of 
 stony consistence, quite insensitive and absolutely 
 fixed ; the lumbar spine and the mass moved as a 
 solid whole. The x-rays showed an opaque area 
 
THE STAMMERING SPINE 97 
 
 corresponding to the mass mentioned, the nature of 
 which admitted of no doubt. Nothing, of course, 
 could be done beyond telling the patient to make 
 the best of the situation and to get as much com- 
 pensatory movement in the parts by means of 
 exercise as was feasible. I afterwards heard that a 
 diagnosis of malignant growth had been made, but 
 this was obviously the result of either an imperfect 
 examination or because the practitioner concerned 
 had previously had no experience of such cases. 
 These masses, resulting from traumatic myositis 
 ossificans, are, in some respects, it is true, suggestive 
 of a growth ; indeed, operations have been proposed 
 in some cases in consequence, but to any person 
 familiar with the condition the mistake is not likely 
 to occur. 
 
 A CLINICAL SIGN. 
 
 The Stammering Spine. In the condition re- 
 ferred to in the foregoing remarks the rigidity is 
 so complete that there is little probability of any 
 mistake occurring. There is, however, a form of 
 persistent rigidity which, although only apparent, 
 is at first sight so absolute that unless an examina- 
 tion of the right kind be made, errors in diagnosis 
 are more than probable. This form of rigidity 
 is due to muscular contraction or spasm, and is 
 most frequently met with in muscular rheumatism, 
 
 H 
 
98 STIFFNESS OF THE SPINE 
 
 hysteria, neuro-mimesis, and as a consequence 
 of reflex irritation (vide table), and so complete 
 sometimes is the fixation of the vertebrae that a 
 condition of absolute rigidity is produced. Bear- 
 ing in mind the essential factor muscular contrac- 
 tion in these cases, it is obvious that any method 
 of examination of a rigid spine should be made with 
 a view to eliminate the question of deception from 
 this condition. 
 
 Excepting cases of inflammation, congenital ab- 
 normality, or central nervous disease, it will be 
 found that when stiffness of a joint, vertebral or 
 otherwise, is due to muscular spasm, relaxation of 
 the muscles concerned for a longer or shorter period 
 is merely a question of putting strain upon them 
 for a sufficiently long time. The relaxation may 
 be only momentary, but it will come, and however 
 short the term of relaxation may be, it is sufficient 
 to provide the key to the situation. 
 
 The administration of an anaesthetic would, of 
 course, at once settle the question of the relation of 
 muscular spasm to the rigidity ; but it should be 
 borne in mind that the anaesthetic, although it may 
 set at rest the question of rigidity, often veils, for the 
 time being, other symptoms of importance. More- 
 over, the administration of an anaesthetic unneces- 
 sarily is not to be commended. In the examination 
 to determine the points under discussion, all that is 
 
THE STAMMERING SPINE 99 
 
 necessary is that the patient, stripped to the hips, 
 standing with the back to the observer, should bend 
 forward in the usual way, the lower limbs being 
 kept extended at the knee ; the hand of the observer 
 at the same time resting upon the rigid portion of 
 the spine. The bending forward of the trunk having 
 been carried out as far as possible, the patient should 
 not immediately begin to resume the upright position, 
 as is usually done in the examination of spinal cases, 
 but should maintain the bent position for a consider- 
 able period, at all events for two or three minutes. 
 It will then be found that if the rigidity is* due to 
 muscular action, a slight quivering of the muscles 
 lying under the hand of the investigator will occur ; 
 this quiver will, if the bent position be still main- 
 tained, be replaced by a series of jerks (stammering), 
 until in some cases the flexibility of the vertebral 
 column can be freely established. In infants and 
 the very young this method is obviously imprac- 
 ticable, but in such the same end is attained by 
 resorting to the only delicate test of spinal rigidity 
 available namely, by placing the small patient flat 
 on the back and lifting it off the couch or bed by 
 one hand placed beneath the spine ; when held up 
 in this way for a minute or so, if the rigidity is due 
 to muscular causes, the result mentioned will follow. 
 So far as I know, this method of testing the rigidity 
 or flexibility of the spine of infants or very young 
 
 H 2 
 
100 STIFFNESS OF THE SPINE 
 
 children is the only truly reliable one. The method 
 of placing the child in the prone position and moving 
 its lower limbs and pelvis from side to side is far less 
 sensitive. I know of no more important point in 
 the diagnosis of rigidity of the spine than that afforded 
 by the ' stammering spine/ and it is a point which 
 may altogether escape notice if the patient, whilst 
 being examined, is allowed, after bending in the 
 orthodox manner, to resume the erect position 
 immediately. 
 
 SOME ILLUSTRATIVE CASES. 
 
 A boy, just passing from the adolescent period, 
 of a markedly neurotic type, and the offspring 
 of somewhat ' highly strung ' parents, was re- 
 ported to have had a slight accident in the foot- 
 ball field, followed by some pain and stiffness in 
 the lumbar region. He apparently recovered, but 
 as he walked rather stifHy and became easily tired, 
 he was seen by a medical man, who, finding rigidity 
 of the spine, came to the conclusion that the lad was 
 the subject of tuberculous disease, and advised com- 
 plete rest on the back for a period of twelve months, 
 to be followed by the use of a spinal jacket. As this 
 rather drastic suggestion came upon the parents 
 as a complete surprise, they were reluctant at first 
 to resort to the treatment without the support of a 
 
THE STAMMERING SPINE 101 
 
 further surgical opinion. The physician concerned 
 in the case consequently referred the boy to me. 
 Upon examination, he was found to be an elongated 
 'weedy' looking subject, obviously still suffering 
 from the nervousness of adolescence ; discomfort 
 in the lower part of the back was complained of, and 
 he tired very quickly after exertion ; he preferred to 
 rest or loll on a sofa, &c., rather than to exert himself, 
 on the grounds of the discomfort, sometimes amount- 
 ing to pain, which followed any but the slightest 
 efforts at movement. The whole of the lumbar 
 and dorsal spine was stiff ; at first sight absolutely 
 so, but upon applying the test I have described a dis- 
 tinct quivering in the erector spinse soon commenced, 
 and the typical stammering movements followed. 
 Further careful examination having failed to elicit 
 any other evidence whatever of tubercle, I advised 
 massage and rational exercise under proper supervi- 
 sion ; these were subsequently carried out, with the 
 result that in a couple of months the boy was sound 
 and strong. He went at once to a public school, 
 and never ailed anything afterwards, although it is 
 some years since the treatment was carried out. It 
 is clear that in this case a knowledge of the stammer- 
 ing symptoms in rigidity of the spine prevented the 
 adoption of a treatment of long-continued confinement 
 and rest, which from every point of view wmild have 
 been bad. 
 
102 STIFFNESS OF THE SPINE 
 
 A middle-aged man, who came of a tuber- 
 culous stock, complained of a very intractable 
 kind of lumbago, which persisted so long as to 
 become a serious obstacle to business. Upon ex- 
 amination the lumbar spine was apparently quite 
 stiff, and remained so during the ordinary test of 
 bending with immediate return to the erect posi- 
 tion. The erectores spinse were very hard and rigid. 
 Under the stammering test, however, the usual 
 quiver in the muscles, followed by subsequent 
 jerkings, was felt. The question of tuberculous 
 disease having been thus eliminated the patient was 
 sent to a continental watering-place and returned in 
 good health. The occurrence of this symptom of 
 stammering may be held to be absolute proof of the 
 absence of organic disease of the vertebral column. 
 
 THE STAMMERING JERK. 
 
 It is interesting to note, although I do not know 
 that the fact is of any special clinical value, that in 
 the stammering spine the jerks occur in two forms 
 in the one the first jerk, which is brief, is followed 
 by a succession of increasingly long relaxations in 
 the muscles until sometimes a condition of nearly 
 natural suppleness is arrived at. The process may, 
 in fact, be diagrammatically expressed by the 
 following markings : 
 
INTERMITTENT STIFFNESS 103 
 
 In the other form the first muscular relaxation 
 is long, those which succeed becoming shorter and 
 shorter until, in some cases, a condition of appar- 
 ently complete rigidity may be resumed, the dia- 
 grammatic expression being thus : 
 
 The former type is, so far as I know, limited to 
 cases of ' hysteria ' and neuro-mimesis ; the latter 
 is mainly confined to cases of rheumatism and recent 
 sprains and wrenches. 
 
 INTERMITTENT OR RELAPSING STIFFNESS. 
 
 Neuro-Mimesis in Relation to Spinal Rigidity. 
 Neuro-mimesis, the nervous mimicry of disease, 
 does not, I fancy, attract so much attention now as 
 it did twenty or twenty-five years ago, although, judg- 
 ing from personal experience, it is quite as important 
 a clinical factor now as it was then. I may, perhaps, 
 be pardoned if I remind you that the so-called 
 intelligence displayed by young children is largely 
 due to the results of pure imitation, and that during 
 the early years of life the tendency, especially in 
 girls, to imitate the characteristics and peculiarities 
 of those with whom they continually associate is 
 very strong ; this imitative faculty being particularly 
 attracted in certain subjects by any characteristic 
 which is especially pronounced. Occasionally it 
 
104 STIFFNESS OF THE SPINE 
 
 happens that an unusually susceptible child, thrown 
 constantly in contact with another individual, whether 
 child or adult, suffering from some deformity or 
 peculiarity, will unconsciously imitate the peculiar 
 characteristic in a remarkable way. The commonest 
 conditions thus imitated are, in my experience, 
 disease of the hip and Pott's disease. Confining 
 ourselves to the consideration of the subject of this 
 lecture, I have seen cases of slight angular curvature 
 at the cervico-dorsal junction so accurately imitated 
 as to deceive very shrewd observers. A peculiarity, 
 however, of the spurious condition is that it occurs 
 in precisely the same position, and assumes as nearly 
 as possible the same characteristics, as the original 
 case, whereas in the case of organic disease, especially 
 tubercle occurring in a second member of the same 
 family, it is very rarely indeed of precisely the same 
 form and distribution as the first the very similarity 
 of the two cases should, in fact, arouse suspicion as 
 to the reality of the second. The stammering test 
 will also invariably exclude the existence of organic 
 disease, and if any ultimate doubt remains, the ad- 
 ministration of an anaesthetic will finally settle the 
 question by completely removing the rigidity if the 
 case be one of the spurious kind. The moral of this 
 matter is as follows : In a case of rigidity of the 
 spine with, perhaps, apparent slight deformity, the 
 mere fact that another member of the family has 
 
NEURO-MIMESIS IN SPINAL STIFFNESS 105 
 
 had tuberculous disease of the vertebral column is 
 not necessarily any evidence that the second case 
 is of the same nature, especially if the manifesta- 
 tions in the second case are precisely similar to 
 those in the first ; in such circumstances the possi- 
 bility of neuro-mimesis should always be borne in 
 mind. 
 
 AN INSTRUCTIVE CASE. 
 
 Some years ago a girl fourteen years old was 
 brought to me for an opinion concerning a curious 
 stiffness about the neck and shoulders, and a pecu- 
 liarity in gait which she had gradually developed in 
 the course of eight or nine months. The attitude was 
 singularly restrained the head was thrust a little 
 forward, the chin being slightly raised ; on turning 
 from side to side the head moved with the shoulders 
 and the neck seemed quite stiff. The general atti- 
 tude was precisely that of Pott's disease in the 
 cervico-dorsal region. The girl was well nourished, 
 very intelligent, and in apparently good general 
 health. She complained of no actual pain, but 
 readily became tired, and had given up any attempt 
 to play games. On removing the clothes the posi- 
 tion of the head and neck was as already described, 
 the lower cervical and upper dorsal spine was appar- 
 ently quite stiff, the vertebra prominens projected 
 much more than is usual (which suggested a 
 
106 STIFFNESS OF THE SPINE 
 
 condition of slight angular curvature), there was no 
 tenderness or thickening of any kind, the bony 
 outlines could be clearly made out, and the ordinary 
 bending test only confirmed the impression of stiff- 
 ness of the column. The stammering test I did not 
 use, as I had not then become acquainted with it. 
 I felt, however, that there was something deceptive 
 about the case, and therefore examined the child 
 under an anaesthetic, with the result that all the 
 symptoms disappeared, the spine becoming during 
 the anaesthesia entirely natural, whilst upon recovery 
 from the anaesthesia the abnormal condition was 
 resumed. What the condition during ordinary sleep 
 was I do not know, as so far as I can recollect I never 
 had an opportunity of satisfying myself on that 
 point. The case puzzled me a good deal at the 
 time ; there was clearly no organic disease, and as 
 a hysterical manifestation it was most unusual. It 
 transpired on further inquiry that the girl had for 
 a year or more before I saw her been constantly 
 in the company of a patient who had tuberculous 
 disease of. the cervico-dorsal spine, and who wore a 
 leather support having a collar round the neck to 
 support the head and chin. This appeared to settle 
 all doubt as to the nature of the case, which was one 
 of nervous mimicry of the most striking kind. The 
 position in which the patient held her head was, 
 it will be noted, precisely that in which the head 
 
REFLEX IRRITATION AS A CAUSE 107 
 
 of a patient would be whilst wearing a spinal support 
 of the kind mentioned. Removal from the associa- 
 tions under which the abnormality developed, and 
 the use of massage and rational exercises, were fol- 
 lowed by great, although somewhat slow, improve- 
 ment. 
 
 The recognition of these cases is of considerable 
 importance, for unless proper means are taken to 
 correct the perverted function the abnormality may 
 become permanent, a result which is all the more 
 likely if in such a case a diagnosis of organic dis- 
 ease be made and the usual treatment by rest and 
 fixation employed. There is no limit to the eccen- 
 tricities which are shown by some of these patients. 
 I remember a remarkable case at St. George's 
 Hospital, in which a clearly neuro-mimetic talipes 
 equino-varus in a girl disappeared under an an- 
 sesthetic and was found on the recovery from the 
 anaesthetic to have been transferred to the opposite 
 foot ; the mistake, however, was not long in being 
 corrected, for in a few hours the abnormality was 
 again located in the foot originally concerned. 
 
 REFLEX IRRITATION AS A CAUSE OF INTERMITTENT 
 SPINAL RIGIDITY. 
 
 The reflex disturbances resulting from intestinal 
 worms in children are so manifold as to be almost 
 
108 STIFFNESS OF THE SPINE 
 
 unlimited ; at the same time I do not know that 
 occasional spinal rigidity is generally recognised 
 as one of them. There is no doubt, however, that 
 intestinal worms do produce this complication, 
 and sometimes in a very alarming degree. A case, 
 for example, came under my notice in which a re- 
 lapsing spinal rigidity of a very pronounced kind 
 disappeared entirely after the passage of a large 
 mass of tape-worm. 
 
 Movable Kidney. The following case speaks for 
 itself. A young woman, twenty-eight years old, of 
 a spare and apparently healthy habit, suffered almost 
 continuously from pain across the lower part of the 
 spine ; the pain, as a rule, was dull, but sometimes 
 it became acute ; stooping was so painful that she 
 found it as a rule almost impossible to pick up any 
 object from, the ground. Upon examination the 
 whole spine below the middle of the dorsal region 
 was stiff when she bent ; there was neither defor- 
 mity nor tenderness, but the erectores spinse were 
 very hard. The stammering test could not be 
 applied as the pain on stooping was too great to 
 allow the necessary attitude to be maintained for a 
 sufficiently long time. On examining the abdomen 
 the recti were rather rigid, and at first resented 
 handling. A little gentle manipulative massage, 
 however, led to their relaxation, and on the right 
 side a distinct mass could be felt, which suddenly 
 
CALCULI AS CAUSATIVE FACTORS 109 
 
 slipped away in the characteristic manner of a 
 movable kidney. This was followed by a sense of 
 relief like that which was usually felt when sudden 
 or rapid modification in the symptoms happened. 
 It therefore seemed pretty clear that the whole 
 trouble might be due to a movable kidney which 
 was prevented from returning to its normal site by 
 some band or constriction after it had become dis- 
 placed. At all events the probability of this view 
 being correct was strong enough to justify the re- 
 commendation of an operation to fix the kidney. 
 This was accordingly done, with the result that no 
 further spinal symptoms had occurred up to the 
 time when she was last seen three years after the 
 operation. 
 
 CALCULI AS CAUSATIVE FACTORS. 
 
 Renal Calculus. Spinal rigidity, generally of the 
 relapsing type, is met with in cases of renal calculus. 
 I was consulted by a medical student, twenty-four 
 years old, on account of a persistent pain in the spine 
 over the dorso-lumbar region, which varied in degree 
 from a dull ache to an acute agony ; it was increased 
 by movement, especially jolting. There was no 
 tenderness or deformity, and violent succussion of 
 the shoulders caused no increase of discomfort ; 
 on the right side the pain passed round the belly 
 ' like half a girdle/ When I first saw him the lower 
 
110 STIFFNESS OF THE SPINE 
 
 half of the vertebral column was quite stiff in all 
 movements, and he walked in the constrained 
 manner of a man with a stiff spine. The stammer- 
 ing test led to a quivering in the erector spinae, but 
 the pain was so much increased by stooping that 
 the test could not be fully carried out ; but what 
 I felt was sufficient to assure me that no organic 
 disease of the spine existed. There were no sym- 
 ptoms referred to the kidney, and the urine was 
 normal saving the existence of a few crystals of 
 oxalate of lime. A week later, although the sym- 
 ptoms of pain, &c., were much the same as before, 
 the spine was quite supple and the constrained gait 
 in walking, which was present before, no longer 
 existed. The renal region now was a little tender, and 
 the muscles resented pressure to a slight extent. In 
 five successive examinations the spine was quite stiff 
 in two, quite supple in three. In the renal tenderness 
 no change occurred, and the urine remained normal. 
 An x-ray exposure was made, and there seemed to 
 be an opacity in the right kidney, but the case 
 occurred in the earlier x-ray period, and the result 
 was too indefinite to be conclusive. I finally ex- 
 plored the right kidney and removed an oxalate of 
 lime stone as large as a hazel nut. The operation 
 proved entirely successful, as all the symptoms dis- 
 appeared and did not recur. The patient had 
 unfortunately, in attempting to relieve the pain, 
 
TRANSIENT RIGIDITY 111 
 
 contracted the morphia habit before I saw him, and 
 the ultimate result was lamentable. 
 
 Stone in the Ureter. Within the last eighteen 
 months I have seen a remarkable case of this kind 
 in which spinal rigidity and pain were the conditions 
 complained of. The patient was a stoutish, middle- 
 aged man, of an obviously gouty habit. The pain, 
 which was constant, was referred to the lumbar 
 region, and was at times intense. When first seen, 
 rigidity of the lumbar spine was apparently complete, 
 and the lower dorsal vertebrae moved less freely than 
 was normal. The stammering test established the 
 fact that there was no organic disease of the spine. 
 On one occasion the rigidity was altogether absent. 
 The a?-rays showed a stone of small size in the ureter. 
 This, under the flushing-out treatment, was subse- 
 quently passed, and the symptoms complained of did 
 not occur again. 
 
 TEMPORARY OR TRANSIENT RIGIDITY. 
 
 It is manifest that transient rigidity may arise 
 from several conditions affecting the vertebral column 
 apart from those the result of reflex causes. The 
 only cause, however, which I need mention here is 
 rickets. The general belief that the rickety spine is 
 a supple spine is universally taught, and rightly so ; 
 but it is nevertheless a fact that during the gastro- 
 
112 STIFFNESS OF THE SPINE 
 
 intestinal disturbance in rickets the spine may for 
 a period be rigid. 
 
 In conclusion it may not be amiss to remind you 
 that whilst on the one hand spinal rigidity is not 
 necessarily an indication of disease of the vertebral 
 column, its absence, on the other hand, does not 
 show that the column is free from lesion, since in 
 some cases of tubercle considerable changes in the 
 condition of the column may occur without its 
 suppleness being interfered with. 
 
RATIONAL TREATMENT OF STIFF JOINTS 113 
 
 LECTURE V 
 
 THE KATIONAL TREATMENT OF STIFF JOINTS BY 
 FORCIBLE MANIPULATION, COMMONLY CALLED 
 ' BREAKING DOWN/ 
 
 IN the previous lectures I have endeavoured to show 
 the way in which stiffness and other disabilities of 
 the joints arising from fractures and other injuries 
 may be prevented. My present purpose is to indi- 
 cate the rules which should be observed in the 
 management of stiff joints generally upon principles 
 which are rational, as opposed to the casual methods 
 which have been hitherto not uncommonly used. 
 Increased intelligent appreciation of the causes which 
 lead to stiffness of articulations, and of the circum- 
 stances which influence them, has fortunately led 
 to a more rational understanding among surgeons 
 generally, and has enabled the ordinary practitioner 
 to deal with these conditions in a manner which was 
 quite unappreciated a few years ago. In using the 
 term ' rational management ' I mean management 
 based upon reasonable principles, *as opposed to the 
 happy-go-lucky methods of the so-called bone-setters, 
 
114 RATIONAL TREATMENT OF STIFF JOINTS 
 
 who, until recently, have practically had the mono- 
 poly of the management of cases of this kind. The 
 term ' stiff joint ' I wish to limit for my present 
 purpose to those joints which are fixed by fibrous 
 adhesions or matting around or in the vicinity of the 
 articulation ; cases of bony ankylosis of course do not 
 come under consideration in the present discussion. 
 
 Stiffness in a joint, therefore, in the sense in 
 which I am now speaking, may be due to adhesions 
 inside the articulation ; to stiffening 'of the capsule by 
 adhesion, or matting of the parts immediately around 
 it ; to temporary muscular rigidity, or to permanent 
 rigidity of muscles, from physiological shortening, 
 and finally to adhesion of muscles (e.g. in fracture) 
 at a point more or less remote from the articulation. 
 The first object in any case in which ' breaking 
 down ' of a stiff joint is contemplated is to ascertain 
 whether there is, or whether there is not, bony anky- 
 losis. This can generally be easily ascertained by 
 examination under an anaesthetic, and as a rule with- 
 out an anaesthetic, especially if the x-rays be used 
 as a help. But the x-rays in themselves are apt 
 to be extremely deceptive, and will sometimes show 
 a joint to be apparently ankylosed which, under 
 an anaesthetic, may, with a little discreet manipula- 
 tion, be made to bend almost to its complete extent. 
 On the other harld, I have seen a skiagram showing 
 a joint apparently sound and in good working con- 
 
MODE OF EXAMINING STIFF JOINTS 115 
 
 dition which, when examined after amputation, was 
 found to be absolutely ankylosed by buttresses of 
 bone. The evidence of the x-rays, therefore, in the 
 conditions which I am now considering, must not be 
 regarded as above suspicion. 
 
 METHOD or EXAMINATION. 
 
 In examining a joint in order to determine the 
 degree of stiffness, taking for an example a knee- 
 joint, because the knee is the articulation most 
 commonly concerned and the one about which more 
 mistakes are probably made than any other articula- 
 tion, there are some practical details which may be 
 worth pointing out, as they are of importance. 
 
 The main difference felt upon manipulation in a 
 joint which is in a condition of bony ankylosis and 
 one which is merely stiff from adhesions or matting 
 is, of course, that the former is rigid in its stiffness 
 like a bar of iron or wood, and the latter gives a 
 sensation of 'spring' in the line of the joint on 
 attempts at bending. In some cases the signs of 
 the two conditions of true ankylosis and extreme 
 rigidity from adhesions approach so nearly to one 
 another that it is only by the most careful manipula- 
 tion that they can be differentiated. It is by at- 
 tempts at flexion alone of any joint that a reliable 
 judgment in this respect can be arrived at ; the 
 
 i 2 
 
116 RATIONAL TREATMENT OF STIFF JOINTS 
 
 evidence of attempts at extension are nugatory and 
 deceptive. In testing the rigidity of a joint by flexion 
 the following points are essential to be observed in 
 different cases : (1) The proximal bone must lie along 
 its whole length upon a flat surface (e.g. a kitchen 
 table) to which it can be firmly applied by pressure 
 of the hands of an assistant or some other means. 
 
 (2) The end of the flat surface must lie exactly across 
 the middle of the affected articulation, so that when 
 pressure is made upon the distal bone the stress of 
 strain comes accurately upon the line of the joint. 
 
 (3) The pressure upon the distal bone should be 
 such as is likely to elicit the sense of ' spring ' in the 
 articulation most correctly ; to this end the distal 
 bone should not be grasped in the hand and forcibly 
 bent continuously, but the hand of the manipulator 
 should merely be laid upon the distal portion of the 
 limb and a decided but not too sudden impact given ; 
 a sense of spring in the line of the joint will in this 
 way be much more easily determined than by the 
 firm grasp and forcible attempts at flexion usually 
 employed, since the forcible attempts referred to are 
 liable to convey a sense of spring which involves not 
 the joint alone but the whole limb. 
 
 By the above method it is almost impossible to be 
 deceived as to the nature of the stiffness even in the 
 most difficult cases. In an ordinary way the follow- 
 ing plan will suffice. One hand of the manipulator 
 
MODE OF EXAMINING STIFF JOINTS 117 
 
 should be placed on the flexor side of the joint, say, 
 for an example, the knee, the limb being poised upon 
 the hand thus placed ; the opposite hand taking the 
 leg just below its middle, attempts are made to flex 
 the knee whilst upward pressure is made by the 
 hand which underlies the joint. Any material spring 
 that there may be in the articulation will be felt im- 
 mediately, not by the hand which is on the leg, but bij 
 that tvhich is beneath the joint. By such a method of 
 examination a very slight amount of spring in an 
 articulation can be appreciated by any person pos- 
 sessing an average acuteness of sensation, and in a 
 case of stiff joint in which there is a sufficient amount 
 of spring to be appreciated in this way there is a 
 strong chance, provided that the other conditions 
 to which I shall refer presently are favourable, of 
 a cure being effected by discreet forcible manipu- 
 lations. 
 
 It is stated that a valuable indication of the 
 existence of bony ankylosis on the one hand and 
 mere stiffness on the other is the absence or presence 
 of pain after violent manipulation under an anaesthe- 
 tic, the subsequent occurrence of pain in the line of the 
 articulation being held to be in favour of the absence 
 of bony ankylosis. No reliance can be placed on 
 this test, as in certain cases of bony ankylosis follow- 
 ing upon tubercle manipulations are always followed 
 by pain of variable severity. Of course, the proper 
 
118 RATIONAL TREATMENT OF STIFF JOINTS 
 
 appreciation of minute differences in rigidity must to 
 a great extent be dependent upon the delicacy of 
 the sense of touch in the manipulator, but in a 
 general way the distinction is not difficult. 
 
 POINTS FOR CONSIDERATION IN DECIDING UPON THE 
 PROPRIETY OF ' BREAKING DOWN ' A STIFF JOINT. 
 
 Having determined that the joint is in a condition 
 in which the question of ' breaking down ' may be 
 legitimately considered in other words, that the 
 joint is not in a condition of bony ankylosis the next 
 point to be decided is whether the breaking down 
 is practicable on the one hand and desirable on the 
 other. With regard to practicability it may be at 
 once conceded that any joint which has become stiff 
 from any other condition than that of bony ankylosis 
 can as a rule be broken down if sufficient force is 
 used, provided that the anatomical relations of the 
 parts are normal ; but sometimes the strength of the 
 adhesions is greater than the strength of the bone, in 
 which case a fracture in or near the joint may occur 
 instead of a breaking down of the adhesions. 
 
 In determining the desirability of the breaking 
 down of a joint the following points require primary 
 consideration : 1. The history of the case. 2. The 
 condition of the articulation. 3. The state of the 
 soft parts around the joint. 4. The condition of the 
 
POINTS FOR CONSIDERATION 119 
 
 muscles acting on the joint. 5. The condition of 
 the bones. 
 
 1. The history of the ease. This is important in 
 relation to the causes of the stiffness. Speaking 
 generally, cases in which the history points to tubercle, 
 to inflammation during malaria, and to disorgani- 
 sation following upon enteric and the exanthe- 
 mata may be regarded as unfavourable for sudden 
 breaking down ; cases, on the other hand, in which 
 the history points to injury, rheumatism, pyaemia, 
 osteo-arthritis, gonorrhoea, syphilis, and to various 
 nondescript types of arthritis, may be regarded 
 as favourable for the treatment, subject of course 
 to the necessary modifications indicated by local 
 conditions which will be dealt with presently. 
 
 2. The condition of the articulation. The point of 
 first importance here is that the relation of the ar- 
 ticular surfaces should be normal, that there should 
 in fact be no displacement, partial or complete. In 
 the case of the knee the free mobility or fixation of 
 the patella is of much moment, since, if the patella 
 be fixed, the bone may be fractured during the bend- 
 ing of the joint, an accident which I have witnessed 
 more than once ; if the patella is freely movable it is 
 perfectly safe from injury during forcible flexion of 
 the knee. 
 
 Apart from the conditions just mentioned, the 
 joint may be of normal temperature to the touch or 
 
120 RATIONAL TREATMENT OF STIFF JOINTS 
 
 it may be hot ; further, it may contain fluid in excess 
 or it may not. A heated joint without fluid is the 
 least favourable for radical measures, since such a 
 joint usually contains a limited tuberculous focus 
 which upon the breaking down of the joint is almost 
 certain to become acute and diffuse. Moderate heat 
 with effusion is no bar to radical measures, indeed is 
 at times a strong indication for their adoption, since 
 the effusion and heat are often due to the dragging 
 of adhesions, which, if broken through, cease to 
 trouble. All other things being equal, the less the 
 rigidity of a joint the more favourable it is for treat- 
 ment by immediate forcible flexion, provided that 
 the defect is inside the articulation. In some cases, 
 when the defect is extra-articular, it is otherwise. 
 
 3. The state of the soft parts around the joint. 
 Scars, sinuses, and general adhesion of the soft 
 parts about a joint do not as a rule centra-indicate 
 forcible bending, if these conditions are confined to 
 the extensor aspect and if no nerve is involved in the 
 cicatrices. Should the parts be reduced merely to 
 a thin ill-nourished scar area, of course the risk of 
 splitting this ill-nourished tissue must be borne in 
 mind. Contracted scars and shortened normal 
 tissues on the flexor side of a joint which has been 
 for a long time flexed are very important, and if the 
 flexion is extreme the propriety of extending the joint 
 forcibly must be carefully weighed. As a rule in 
 
POINTS FOR CONSIDERATION 121 
 
 such cases immediate forcible extension is contra- 
 indicated, gradual extension by the aid of massage and 
 gentle passive movements being preferable in con- 
 sequence of the tendency of the contracted skin and 
 subcutaneous tissues to split transversely during 
 violent extension. I well remember a remarkable 
 case of this kind occurring in the theatre of 
 St. George's Hospital. A patient, whose knee had 
 been flexed for some years, was placed under an 
 anaesthetic for purposes of examination, as the 
 defective joint, for sufficient reason, had either to 
 be straightened or removed. A somewhat forcible 
 attempt to extend the limb was followed by 
 considerable success, but the soft parts across the 
 middle of the popliteal space split transversely, 
 leaving the main vessels and nerves exposed. 
 Amputation was immediately performed. This case 
 is an extreme one, but illustrates the point under 
 discussion. In fact it is true generally that forcible 
 flexion of stiff joints is not only more successful than 
 forcible extension, but is comparatively devoid of risk 
 if intelligently practised. The most difficult cases of 
 stiff joint of all to deal with in my experience are 
 those in which a nerve (usually the ulnar at the 
 elbow) is involved in a cicatrix outside the joint. 
 The pain in some of these cases makes anything like 
 forcible bending quite impossible unless the nerve 
 can be freed from the cicatrix in which it is involved 
 
122 RATIONAL TREATMENT OF STIFF JOINTS 
 
 a measure which, is sometimes impossible without 
 producing paralysis, if it does not already exist, or 
 increasing it if already present. I have under my 
 care at the present moment a case of moderately stiff 
 elbow from gun-shot wound, which so far as the 
 joint itself is concerned is perfectly amenable to 
 treatment ; but, in consequence of some sloughing 
 which occurred at the inner side of the articulation, 
 the ulnar nerve is so densely implicated in scar 
 tissue that any material movement excites intolerable 
 pain and temporary paresis. The case is practically 
 oiitside the limits of active surgical treatment, since 
 the nerve cannot be freed from its scar tissue without 
 suffering considerable damage, and the remaining 
 alternative, excision of the joint, does not promise a 
 result sufficiently better than the rather stiff joint 
 which now exists to make it preferable. This again 
 is an extreme case, but it is none the less instructive, 
 particularly as the case was sent for treatment solely 
 from the point of view of the stiff joint, the 
 importance of the nerve complication not having 
 been recognised. It is always well to bear in mind 
 in cases of stiff joint that some of the greatest pain 
 during the radical treatment may arise from con- 
 ditions apart from the joint itself. 
 
 4. The condition of the muscles acting on the 
 joint. The muscles in a case of stiff joint are natu- 
 rally wasted more or less. The wasting may be slight 
 
POINTS FOR CONSIDERATION 123 
 
 or extreme, and in the latter case the muscles on the 
 proximal side of the joint may be reduced to a con- 
 dition which is little better than that of fibrous cords. 
 The wasting, whether slight or excessive, affects the 
 proximal muscles mainly, i.e. the muscles which act 
 directly on the joint under ordinary circumstances. 
 
 Speaking generally, the less the amount of 
 mobility in the joint the greater is the wasting of 
 the muscles, for obvious reasons. The wasting, how- 
 ever, is not always the same in similar cases, although 
 these may be in all other respects apparently the 
 same. From the point of view of the radical treat- 
 ment of stiff joints by forcible bending, muscle waste 
 in itself is not of great importance, but rigidity of 
 the muscles in addition to wasting is of considerable 
 consequence. Muscular rigidity in these cases arises 
 mainly from two causes : first, physiological shortening 
 from the effects of disease or persistent complete dis- 
 use ; and secondly, matting of the muscles or muscle 
 to the underlying bones from inflammation or injury, 
 as examples of which may be mentioned the adhesions 
 resulting from cellulitis or periostitis, and the matting 
 of the parts about a fracture. The more rigid the 
 muscle the greater must be the care exercised in the 
 forcible bending of these cases, and it is important to 
 determine as far as possible to what extent, if any, 
 the stiffness of the joint is due to the rigidity of the 
 muscles. Speaking generally, it will be found that the 
 
124 RATIONAL TREATMENT OF STIFF JOINTS 
 
 greater the rigidity of the muscles the less favourable 
 are the cases for the radical treatment. Although 
 muscular rigidity in itself is no actual bar to attempts 
 at breaking down, these when rigidity is present 
 should be made with great care, as not only may 
 rupture of muscle occur, but, what is worse, a bone 
 may give way (Plate XI). The explanation of the 
 danger of the latter calamity lies in the fact that 
 where a joint has been for a long period quite stiff 
 and the muscles extremely wasted the bone is always 
 to some extent wasted also, a very important fact 
 in connection with the present discussion and one 
 which I do not think is sufficiently recognised. In 
 fact the condition of the muscles is a fair indication 
 of the state of the bone in the matter of strength ; 
 wasted rigid muscles indicate a weak bone, and vice 
 versa. 
 
 5. The condition of the bones. Beyond w^hat has 
 been already indicated there is little to be added under 
 this head. Any obvious indication of bone weakness, 
 such for example as loss of tissue, may in some 
 cases altogether negative the propriety of breaking 
 down a stiff joint, and in all cases should lead to 
 great care in manipulation. On the other hand, it is 
 well not to assume, because a bone, as sometimes hap- 
 pens, is thicker than usual from some pathological 
 change, e.g. osteitis, that it is stronger than usual. 
 Although as a rule bones so affected are stronger over 
 
Plate XI. 
 
 Skiagrams of an ankylosed knee-joint before and after ill-advised forcible flexion. 
 
POINTS FOR CONSIDERATION 125 
 
 the actual area of the thickening, they are not always 
 so immediately beyond, and I remember seeing a 
 fracture of the femur in a middle-aged man which 
 occurred during the breaking down of a knee-joint, 
 the fracture having occurred at the extreme upper 
 limit of considerable thickening of the lower end of 
 the femur from old-standing osteitis. In this con- 
 nection the tendency of a new growth to simulate 
 simple bony thickening must not be lost sight of. 
 
 Assuming that in all cases 'the milder measures 
 of massage exercises and passive movements have been 
 tried without effect or with only partial success, the 
 main points relating to the desirability or the reverse 
 of resorting to the radical method of the forcible 
 bending of stiff joints may be summarised generally 
 as follows : 
 
 1. The less the movements of the articulations 
 are restricted the better is the prospect of the radical 
 method. 
 
 2. Fibrous ankylosis resulting from tuberculous 
 disease, unless very slight indeed, should not be 
 forcibly broken down. If in such cases the joint be 
 fixed in a position which is inconvenient or painful to 
 the patient, rectification of the deformity should, in 
 joints where such a course is possible (e.g. the hip), be 
 effected by an osteotomy at some distance from the 
 joint, and not by ' breaking down/ 
 
 3. A stiff joint which is hot to the touch whilst it 
 
126 RATIONAL TREATMENT OF STIFF JOINTS 
 
 contains no -fluid is unfavourable for forcible bending, 
 the condition being usually due to tubercle in a 
 quiescent but dangerous stage. Forcible bending 
 in such cases is commonly followed by the lighting 
 up of the quiet tubercle which results in abscess or 
 worse developments. 
 
 4. A stiff joint which is hot to the touch whilst it 
 contains -fluid is not unfavourable for breaking down 
 unless the ankylosis is practically complete, heat 
 with effusion being commonly due in chronic incom- 
 plete stiffness to the dragging upon adhesions, the 
 rupture of which cures the symptoms. If the 
 ankylosis is complete, or nearly so, and there is 
 coincident effusion and heat, breaking down of the 
 joint should be conducted with great care and 
 caution, as in such cases there sometimes exists a 
 small area of diseased bone in the joint or im- 
 mediately outside it. 
 
 5. Effusion without appreciable heat may be 
 ignored for ordinary purposes in deciding as to the 
 propriety of the forcible bending of a joint. 
 
 6. The less the muscles acting on the joint are 
 wasted, and the better their physiological condition, 
 the more freely, cceteris paribus, may attempts at 
 breaking down be approached. 
 
 7. Rigid or adherent muscles should be regarded 
 as unfavourable factors in this treatment, but are not 
 insuperable objections. 
 
POINTS FOR CONSIDERATION 127 
 
 8. Wasted muscles which are not rigid may be 
 disregarded except in very long-standing cases, in 
 which extreme muscle-waste is invariably associated 
 with weakening of the bones ; such cases, therefore, 
 should obviously be approached with caution. 
 
 9. The ideal condition of a stiff joint for the 
 purposes of the radical treatment by breaking down 
 may be said to be as follows : moderate stiffness, 
 absence of heat and effusion, with flaccid muscles. 
 Any joint which is not absolutely stiff, which is not 
 hot to the touch, which contains no fluid, and in 
 which the muscles acting upon it are not rigid or 
 adherent, may be broken down with impunity. 
 
 10. The neurotic element in stiff joints must be 
 borne in mind. Stiff joints which are without in- 
 creased local heat and effusion may, if the muscles 
 are not wasted, be regarded for practical purposes as 
 neurotic in origin. 
 
 POINTS KELATING TO THE DETAILS OF FORCIBLE 
 MANIPULATION or JOINTS. 
 
 The following summary includes only the more 
 important points relating to the method of procedure, 
 and is of course in no sense exhaustive ; but the 
 points referred to are, so far as my experience goes, 
 those which are most worthy of note. 
 
 1. Although not invariably necessary, an anaes- 
 thetic should be given in all cases. The anaesthesia 
 
128 RATIONAL TREATMENT OF STIFF JOINTS 
 
 should be profound, and the behaviour of the muscles 
 of the affected part should be observed whilst the 
 patient passes under the influence of the anaesthetic. 
 The more these muscles twitch and contract during 
 this period, the better as a rule is the prospect of 
 the treatment. In neurotic cases free spontaneous 
 movement of the stiff joint frequently occurs at this 
 time. 
 
 2. All attempts at the breaking down of stiff 
 joints should, unless circumstances make it impractic- 
 able, be preceded by a methodical course of massage 
 and passive movement. This is especially indicated 
 when the muscles are rigid and apparently adherent. 
 The effect of a course of massage in such cases is 
 most marked in loosening the rigidity of the muscles, 
 which frequently leads to considerable diminution in 
 the stiffness of the joint. Joints treated in this way 
 often become easily manageable by breaking down 
 after the massage, although they may have previously 
 appeared almost hopeless. 
 
 3. The first forcible movement made in attempts 
 at breaking down a joint should be flexion. Extension 
 should never be employed as the first movement. 
 
 4. The opposing force across which the joint is 
 bent should be placed exactly in the line of the articula- 
 tion, and not upon the bone immediately above that point. 
 When possible the whole length of the proximal bone, 
 when it is a long bone, should be applied to a flat 
 
DETAILS OF THE METHOD 129 
 
 surface, a table for example, the end of which, with 
 a thick blanket laid over it, should be exactly in the 
 line of the articulation. The proximal portion of the 
 limb should be kept firmly applied to the flat surface 
 by the hands of an assistant whilst the manipulator 
 manages the distal part. In the case of the elbow 
 and similar joints, the opposing force (the hand of 
 the manipulator, or a padded bar) should be carefully 
 placed in the flexure of the joint exactly in the line 
 of the articulation. 
 
 5. The attempt at flexion should be made by 
 means of steady intermittent movements, not by one 
 sweeping motion. Extension should be made by one 
 continuous pull or push, the same precautions being 
 taken about the position of the opposing medium 
 as has been indicated in speaking before of its use 
 in flexion. 
 
 6. It is of importance that no attempt at exten- 
 sion should be made until after the greatest possible 
 amount of flexion has been effected. In other words, 
 the breaking-down process should be considered 
 primarily to consist of two stages which are quite 
 distinct, first flexion and then extension, the first 
 being complete before the second is commenced 
 abduction and adduction, circumduction forming a 
 third distinct stage in dealing with joints in which 
 such movements are normally present. 
 
 K 
 
130 RATIONAL TREATMENT OF STIFF JOINTS 
 
 TREATMENT SUBSEQUENT TO THE BREAKING DOWN 
 OF A STIFF JOINT. 
 
 On this matter there is little that requires to 
 
 be said. Nevertheless, judging from what I see 
 
 and hear of the subject, it is still necessary to 
 
 emphasise the fact that no splint of any kind should 
 
 be used after this treatment. Massage and passive 
 
 movement should be used immediately, i.e. within 
 
 twelve hours if possible. Voluntary movements should 
 
 be encouraged as much as possible even at the cost 
 
 of considerable pain. The only indication for the 
 
 interruption of the movements is extreme local heat 
 
 and tension of the joint ; tension without material 
 
 increase of local heat may be ignored. It must 
 
 never be forgotten that the time during which 
 
 adhesions which have been broken down are most 
 
 inclined to re-form is in the course of the first three 
 
 or four days after their rupture ; it is during this 
 
 time that free movements are most urgently called 
 
 for, and this is the time that even now is wasted by 
 
 some practitioners by confining the limb in a splint. 
 
 In difficult cases it is wise in the majority to give 
 
 an anaesthetic again on or about the fourth day (not 
 
 later), to be sure that the amount of mobility obtained 
 
 at the first operation is really preserved. 
 
 In cases in which it has been found possible to 
 
TREATMENT SUBSEQUENT TO BREAKING DOWN 131 
 
 effect only a partial breaking down of a stiff joint, the 
 succeeding attempts at getting a complete result 
 should not be postponed too long. A week is the 
 longest interval which should be allowed, in the 
 absence of special circumstances, between the first 
 and following attempts. 
 
 THE HYPER^EMIC TREATMENT OF STIFFENED JOINTS. 
 
 It is in connection with the treatment of stiffened 
 joints that the method of induced hyperaemia usually 
 associated with the name of Professor Bier, of Bonn, 
 has in my experience proved of the greatest use 
 both as a preventive as well as a curative measure. 
 I am strongly inclined to the view, without being 
 certain about the matter until it has been confirmed 
 by further experience, that the tendency to stiffness 
 and to the formation of adhesions in joint affections 
 is less when obstructive hyperaemic treatment is 
 used as an aid to massage or any other treatment 
 which seems desirable, but it certainly will not take 
 the place altogether of the various other means of 
 treatment in vogue at the present time ; it must, 
 in fact, be regarded as an adjunct, and an excessively 
 useful adjunct, to other treatment. 
 
 It will, however, I am sure, be found that in 
 acute conditions like gonococcal arthritis, acute 
 rheumatic arthritis, and the like, when the hypersemic 
 
 K 2 
 
132 RATIONAL TREATMENT OF STIFF JOINTS 
 
 treatment can be borne, as it usually can be, in the 
 arterial, if not in the obstructive form, that the 
 amount of massage and passive movement subse- 
 quently required to restore the normal joint functions 
 is considerably less than when the ordinary methods 
 have been alone pursued. 
 
 As an aid in the treatment of joints already 
 stiffened by continued immobilisation, or by adhesions 
 in and around the articulation, provided that these 
 have not become too solidly organised, induced 
 hypersemia is of undoubted value a fact in which 
 there is nothing new, as I suppose it is the custom 
 of most of us to prepare a stiffened joint for massage 
 by the use of a very hot compress, with a view to 
 what is commonly called ' softening the parts/ that 
 is to say, to induce a flow of blood to them. This 
 end is more perfectly attained by the hypersemic 
 method of Bier than by any other means, but care 
 is necessary in selecting the form of application, 
 obstructive or arterial, which is to be used. Speaking 
 generally, if the part is painful, as, for example, in 
 certain cases of stiffening after acute ' rheumatic ' 
 arthritis, arterial hypersemia is more comfortable 
 and efficacious than the obstructive form, especially 
 if there is much thickening of the soft parts about 
 the joint. Similar conditions are suitable for obstruc- 
 tive treatment by the somewhat elaborate exhaustion 
 apparatus invented by Bier for the purpose. 
 
THE HYPER^EMIC TREATMENT 133 
 
 Hypersemia induced by bandage pressure is by 
 far the most simple and convenient method, and 
 answers well in cases of stiffening of joints without 
 pain, especially if the surrounding induration or 
 oedema is not great. Capital examples of the good 
 results thus obtainable are afforded by cases of 
 stiffness of the fingers (phalangeal joints) so fre- 
 quently met with after injuries, generally called 
 sprains, but often in reality fractures. 
 
 The comparative ease with which in such cases 
 a finger can be manipulated and bent after its base 
 has been encircled by an elastic band for a period 
 varying from fifteen minutes to an hour or more, by 
 which hypersemia is produced, with the precautions 
 which I have indicated, is often remarkable, although 
 in common fairness it must be admitted that there 
 is no certainty in this result, as in some cases the 
 effect produced seems to be virtually nothing. 
 
 The most striking results of this method of hyper- 
 semic induction have been in my experience obtained 
 in stiffness of the knee-joint, a part which is in many 
 ways particularly well adapted for the treatment, 
 in consequence of the ease with which it can be applied 
 and regulated. One of the most inveterate cases 
 of recurrent stiffness of the knee after successive 
 ' breakings down ' of the joint which I have seen 
 really showed no hopeful sign of cure until the obstruc- 
 tive hyperaemic method by bandage pressure was 
 
134 RATIONAL TREATMENT OF STIFF JOINTS 
 
 adopted, when the tendency to recurrence steadily 
 decreased, and recovery resulted. This case was 
 also remarkable in showing the long period during 
 which obstructive hypersemia could be tolerated 
 with absolute comfort, five or six hours being a 
 common period, at the end of which general osdema 
 below the bandage was well marked. 
 
 FIBRO-LYSIN IN STIFF JOINTS. 
 
 Injections of fibro-lysin have been recommended 
 as a means of softening or loosening the adhesions 
 in stiffened joints. I have not been able up to the 
 present time to satisfy myself that the treatment is 
 of material use. 
 
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Lectures 01 the use of massage 
 
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 UNIVERSITY OF CALIFORNIA LIBRARY