UNIVERSITY OF CALIFORNIA ""FORNIA COLLEGE OF MEDICINE I 8 1971 IRVINE, CALIFORNIA 92664 JPRAINS; THEIR CONSEQUENCES AND TREATMENT BY C. W. MANSELL MOULLIN, M.A., M.D. OXON., F.R.C.S. ENC;. Assistant Surgeon and Senior Demonstrator of Anatomy at the London Hospital ; formerly Radcliffe Traveling Fellow and Fellow of Pembroke College, Oxford. REPRINTED FROM WOOD'S MEDICAL AND SURGICAL MONOGRAPHS. NEW YORK WILLIAM WOOD & COMPANY 1891 WE/IS CONTENTS. INTRODUCTION. PAGE General Considerations, 5 CHAPTER I. The Anatomy of Joints, 9 CHAPTER II. Cause arid Prevention of Sprains, 18 CHAPTER III. Diagnosis, 30 CHAPTER IV. Nature of the Injury, 40 CHAPTER V. Inflammation and the Process of Repair, ..... 60 CHAPTER VI. Imperfect Recovery, 71 CHAPTER VII. Treatment. Cold. Heat. Pressure, , 82 CHAPTER VIII. Treatment. Rest, , . 97 CHAPTER IX. Forcible Manipulation, - - - . 10& CHAPTER X. Massage, 120 CHAPTER XI. Sprains of Tendons, 133 3/3 iv Contents. CHAPTER XII. PAGE Sprains of the Back and Neck, 152 CHAPTER XIII. Internal Derangement of the Knee, 172 CHAPTER XIV. Contraction of the Fingers, 179 CHAPTER XV. Muscular Contraction, 187 CHAPTER XVI. Muscular Wasting, 201 SPRAINS AND THEIR CONSEQUENCES. INTRODUCTION. IT has been my endeavor in the following- pages to confine myself as closely as possible to the commoner forms of sprains, and to those after consequences which may be regarded as directly and immediately dependent on them. Of those which follow more remotely there is no end, and the briefest descrip- tion would lead me far beyond the limits at my disposal. It has been said, and not untruly, that in all probability half the crippled limbs and stiffened joints that are met with every day, date their starting point from the occurrence of some apparently trivial accident of this description. The question of treatment has been dealt with at some length ; and if I have seemed to advocate the adoption of more active measures than those generally employed, especially in the case of long standing inability, it is only that I am firmly convinced of their efficacy and safety when properly carried out. Few injuries are treated with so little consideration as sprains. It is impossible to overlook wounds, owing to the bleeding and pain that accompany them. Fractures, it is un- derstood, require rest and care ; but sprains, in which the tis- sues are torn to such a degree that the damage is far more serious than in many fractures, merely because they are so common, are considered of little or no consequence. It counts for nothing that the part injured is one of the most complicated structures in the body, and particularly liable to inflammation from the constant use to which it is subjected. The construction of a bone is comparatively simple, and its function is merely the passive duty of support. A 6 Sprains; their Consequences and Treatment. joint, on the other hand, is exceedingly complex, and must 4W*iy^De"asslirong 1 for support as the bones between which it lies, but must, (In addition, be capable of executing- rapid and often extensive movements. Two, three, or even more bones may enter into its construction; each of them where it forms part of the joint is faced with cartilage; around them is a protecting capsule of fibrous tissue, lined with a delicate se- creting membrane; ligaments of different kinds hold the bones together; muscles of various size and strength move them one on the other; there is a very large supply of blood-vessels and nerves; and even the tissues round are so adjusted to the sur- faces that with every change in position they fill up the con- stantly-varying spaces round and between the bones. Yet a fracture is regarded as very serious; a sprained joint as quite a trivial matter. In the one the injury is simple and definite in its character; one broken bone does not differ very materially in this respect from another; in the other there is no limit to the variety of hurt sustained, or to the complications that follow. The liga- ments may be torn across, or wrenched off the bone ; the mus- cles may be lacerated ; the tendons displaced bodily from their grooves; the discs of cartilage which are present in some joints between the bones, forced out from their position; the joint cavity filled with blood, and so much more extravasated into the tissues that the discoloration may reach from the ankle to the knee; in short, the tissues may be torn and bruised as ex- tensively as in a dislocation. In many cases the injury is to all intents and purposes the same; the sole difference is that the bones which were wrenched apart at the time of the acci- dent resume their normal relation to each other in the one, while in the other they either remain fixed, or slip a little further aside. Vidal de Cassis appreciated this when he spoke of sprains as temporary dislocations. There is no end to the variety of the injuries that are classed together under this name. It is almost an impossi- bility for two sprains to be exactly alike. Joints differ from each other as widely as they can, both in structure and action : different kinds of tissue enter into their formation, and serve as many separate purposes; the violence that causes the acci- dent is different in every case, both in its force and direction; and the position of the limb at the moment can rarely be the Sprains ; their Consequences and Treatment. 7 same. Some joints are much more liable to injury than others, those especially in the lower limb; and the ankle more than the hip or knee. In some the stress falls on the ligaments; in others, as in the shoulder, on the muscles; very often both suffer together, though in varying proportion ; or without the joint itself being injured, the muscles and tendons may be strained, and give rise to stiffness or weakness that lasts for years. Other considerations also step in and help to make the variety greater. No two persons ever resemble each other exactly; even if this were possible in the earliest years of life, age, habits, occupation, mental temperament, bodily constitu- tion, and many other things, induce such modifications that the slightest difference must at length become immense. Re- pair is not carried on with the same degree of energy in all ; in some complications occur much more easily than they do in others; inflammation breaks out more readily, or other troubles make their appearance; so that, even if by some strange chance the injuries were identically the same in any two cases, it is impossible for them to continue so for any length of time. In this respect peculiarities of constitution are of great signifi- cance; in the majority of instances the ultimate result, whether the joint recovers within a reasonable period, or remains cold, stiff, and untrustworthy for years, depends much more on them, and on the method of treatment adopted, than on the mere fact of a ligament having been torn or only stretched. This, however, is not the only reason why sprains do not merit the neglect with which they are so often treated. Im- perfect recovery in the case of a broken bone is quite excep- tional. Failure of union does sometimes, but very rarely, occur. It is more common for the position of the broken ends to be faulty, so that there is some deformity, or loss of power ; but even when this does happen the after-trouble or incon- venience is only of a temporary character, and at the end of a few weeks or months, at the most, the limb is as strong and firm as ever. Such a thing as yielding, weakness, or continued pain at the seat of fracture is almost unknown, unless there is some exceptional condition of things present. It is not so with sprains. An amount of the thickening round the seat of injury, so slight as altogether to escape notice in the case of a fracture, is quite enough to disable a joint. 8 Sprains ; their Consequences and Treatment. It is true that a large number of sprained joints get well of themselves, or under ordinary domestic treatment, a few, it must be admitted, in spite of it; but even in the young- and healthy, it is not unusual to find the action of the joint seri- ously impaired. There may be merely a general sense of weakness and insecurity, a feeling- that it is not to be trusted as it was before ; or the least attempt at movement may be attended with intolerable suffering. There may be no very visible or definite alteration, or every tissue of which the joint is composed may be more or less disorganized. The skin may be exquisitely tender; the subcutaneous tissues swollen and distended, so that the natural outline cannot even be recog- nized; the muscles may waste away; the tendons become glued to their sheaths, and the interior of the joint be dam- aged to such an extent that, even if everything else were re- stored, it would be impossible for the bone to work evenly or smoothly on the other. Results of this kind, happily, may nearly always be pre- vented. It is true that in some people the power of repair is much more feeble than it is in others; and, no doubt, under some conditions, such as advancing age, joints are especially prone to stiffness and other troubles; but taking them as a whole, few kinds of accidents are more amenable to treatment than sprains, if only two conditions are observed : one, that it is commenced sufficiently early; the other, that it is carried out thoroughly and efficiently, not in a perfunctory manner. Afterwards, if the time immediately after the accident has been allowed to pass by, and the joint is stiff, and recovery imperfect, a great deal may still be done ; but as a rule, the longer the delay the more remote the prospect of perfect restoration. The sudden and startling cures that are so often heard of are really few and far between. It must always be remembered that in surgery, as in most other things, successes are trumpeted abroad, and always quoted as an encourage- ment, while failures are either never heard of, or quite uncon- sciously are forgotten. Much more often recovery is slow and tedious, requiring care and much patience, with days in which improvement is well marked, interspersed among a much larger number on which either no change at all is apparent, or possibly even the pain and stiffness seem actually worse. OHAPTEE I. THE ANATOMY OP JOINTS. THERE is no need in a work of this kind to enter into a de- tailed account of the structure of joints, or to describe minutely the different varieties. I shall only mention a few particulars to which it seems advisable to call attention, as the clinical symptoms that follow injuries do not always correspond with the structures as described in ordinary anatomical treatises. A joint is the connecting- link between two of the rigid parts of the skeleton. Both in the trunk and in the limbs the main support runs down the centre like an axis, and for the sake of mobility is divided into rig-id and flexible segments. The latter are known as joints. Yielding Joints. Some are very simple. There is merely a toug-h layer, made up partly of fibrous tissue, and partly of cartilag-e, uniting- the two bones, and allowing- a limited amount of bending to take place between them in all directions. Bone and fibre-cartilage are developed from the same material; in one part lime salts are deposited, so that it becomes hard and dense ; in another fibres make their appearance, and it is con- verted into ligamentous tissue, capable of bending with ease from side to side, but admirably adapted to resist longitudinal strain. The two are quite continuous, and shade off imper- ceptibly into each other. So slight, indeed, is the difference, that it not unfrequently happens, as a result of disease, or even of old age, that the whole becomes converted into bone, and the joint disappears as such. Others are a little more complicated; but the changes that make their appearance during normal growth, or at certain special periods, show plainly that the difference between them and the more complex ones is only one of degree, and not one of kind. The ends of the bones, if carefully examined, are a little expanded, so as to form a wider surface for the attach- ment of the uniting disc; while the sides are cut away to lessen IO Sprains; their Consequences and Treatment. the weight and to economize material. At the same time the softer intermediate part becomes modified. Owing to the varied character of the strains that fall on its sides and centre, they become different in texture and in power of resistance. The centre, where, whatever the direction in which one bone is bent on the other, there must always be pressure with but little tendency to separation, remains cellular, or becomes so soft and yielding that in some cases it is almost fluid. At the circumference, where in every strain there is compression on the concave side and tension on the convex, the connecting medium gradually becomes more and more fibrous, until by degrees the originally uniform layer of fibro-cartilage is re- solved into a central cavity surrounded by a fibrous capsule and separated from the surfaces of the bones by a layer of cartilage which undergoes no alteration. Such are the joints in the backbone between the bodies of the vertebrae, though in them, at least in man, the change rarely progresses so far. The union is exceedingly strong; the amount of movement allowed at each very limited, though it may take place in any direction ; and the aggregate result of a number close together is very considerable. They are very rarely sprained; their strength, their posi- tion close together, so that any stress falling on one is dis- tributed over a large number, and the limited range of move- ment, prove their safeguard. If the violence is so extreme that something must give way, they either tear across or separate from the bone on one side. Then the injury is to all intents and purposes a fracture, and like fractures is repaired by the deposition of bony material, so that the joint is lost. Movable Joints. It is only a step from joints such as these to those in which there is a well-defined central space, enclosed in a fibrous capsule, and lined with a delicate secreting mem- brane. The development of the various parts is carried further and further, until they differ from each other widely in ap- pearance; but the degree of relationship between them is as near as ever it was; and they are as much connected together, and as closely bound up with each other, as they were before the change. The difference is only one of degree, not one of kind. They become varied in outward appearance and physi- cal properties, because of the different services they have to perform ; but they never lose their mutual sympathy or con- Sprains ; their Consequences and Treatment. 1 1 nection. It is impossible for one part of a joint to be injured, or to suffer in any way, without influencing 1 the rest. Joints are not built up, like machinery, of different and separate parts, any one of which can be injured and replaced without interfering- with the others; they are living organs, which cannot be healthy if the smallest part fails in its duty. The Bones. In the limbs and the more movable joints the modifications are especially great. First, the bones, which are the chief supporting structures, become more highly special- ized. Instead of retaining the same uniform character the ends are altered in one direction, the middle in another. The shaft becomes hollowed out and assumes a cylindrical form, the shape well known to mechanicians as the one best calcu- lated to withstand vertical pressure and lateral strain with the minimum expenditure of material. Here and there the compact walls are strengthened by outlying ridges, so that the cross section in some is almost prismatic. The ends, on the other hand, become wide and expanded, to increase the extent of surface that enters into the formation of the joint; often they are still further enlarged by processes jutting out to afford greater strength and security for the ligaments that hold them together, and more advantageous leverage for the muscles that move them. At the same time the internal structure loses its uniform arrangement. Where the range of movement is limited and equal in all directions, the inter- lacing network of bony spicules, of which the sponge-like in- terior is formed, shows no well-defined differences either in density or arrangement. The outer layer is merely a little more compact and smooth on the surface than the rest. In the more highly developed joints, no matter in what direction the bones are sawn, the dense tissue that forms the outer layer, and the open-work interlacing bars inside, are always so arranged in arches and curves as to diffuse as far as possi- ble over the whole the pressure that falls on any one spot, and to secure the greatest amount of strength and elasticity with the least weight and the smallest expenditure of material. Then the surfaces in contact with the opposite bone become varied in direction and outline in order to correspond to the movements. The more active and vigorous these are, the more changed and uneven they become. In the simplest joint they are flat, and face each other directly, only allowing a 1 2 ' Sprains ; their Consequences and Treatment. certain amount of gliding 1 between them. In others the shoulder and hip, for example the extremity of one bone is hollowed out into a cup into which the other fits, more or less accurately, according" to the degree of support required. In the lower limb, where the need of this is much greater than in the upper, the rounded extremity of the bone forms more than half a sphere, and is so tightly embraced by the sides of the cup, that, even when everything that holds the bones to- gether has been divided, it requires very considerable strength to pull the two apart. In the shoulder, on the other hand, the cavity is shallow, the head of the bone large in comparison, and the range of movement increased thereby at the expense of the security. In a third class, the ends are so modified with regard to each other, that movement can only take place in one plane as on a hinge. In the elbow, for example, the bone is rounded from before backwards, and fits into a correspond- ing depression on the other, rotating in it on an axis that runs from side to side. In the ankle there are stout project- ing processes, one on either side, so that movement is strictly limited to one direction, and lateral bending is impossible. When more complicated movements are required, the modi- fications become greater still. In one instance a ligamentous ring attached at one side is thrown round the neck of a bone, so that it can turn securely in it on its own axis. In another, discs of fibro-cartilage are interposed between the bony sur- faces to deepen the sockets and lessen the impact of shocks ; or, as in the case of the wrist and foot, a number of small bones are so adjusted to each other that the pressure falling on any one of them is diffused and distributed over all the rest. The Fibrous Tissue. These changes are not confined to the bones; in the more movable joints the ligaments become modified quite as much. As already mentioned, in the sim- plest the fibrous tissue that joins the bones together passes directly from the surface of one to a corresponding point on the other. Where the range of motion is a little more exten- sive, the part round the circumference becomes more fibrous, the interior softer and more cellular. In those which admit a wide extent of movement the change is carried further still. The soft central space becomes a well-defined cavity; and the fibrous tissue round forms a firm ligamentous capsule, enclos- ing it, and tying the two bones together. Sprains ; their Consequences and Treatment. 13 The Capsule. Simultaneously with this the point to which the capsule is attached undergoes an alteration. Freedom of movement is easily gained lay increasing- the length of the fibres; but at the same time stability and security are lost, unless, as in the case of the shoulder, the surrounding muscles replace the ligaments in checking and controlling the action. Accordingly, in all cases in which the range of movement ex- ceeds a very small angle, the fibres no longer pass from surface to surface, or even from margin to margin, but are shifted fur- ther back on to the sides of the bones, so that the ends of these are enclosed by the capsule and lie inside the joint. By this arrangement one bone is enabled to glide on the other when any stress falls on it, and freedom of movement is gained without the sacrifice of strength. There are few joints in the body admitting of much angular movement in which one joint does not glide to some extent on the other. The Ligaments. The strength of the fibrous capsule be- comes modified at the same time. Where the amount of movement is but little, and is equal in all directions, there is a uniform and even layer, extending all round the joint from one bone to the other. When the structure of the bones allows bending in one plane only, as in true hinge-joints, the side por- tions springing from the ends of the axis of motion are more highly developed than the rest. Each is attached to a point on the more fixed bone, and radiates from this in a fan-like way on to the other, so that the two are firmly braced together in all positions of the limb. At the back and front it is thin and loose, merely serving to protect the cavity of the joint. By steps such as this the capsule of a joint gradually becomes split up into four divisions, which appear to be so isolated and distinct from each other that they are often called anterior, posterior, and lateral ligaments. They are not, however, sep- arate structures in any sense of the term. They are only sub- ordinate parts of the same that have become differentiated from each other by the difference in the character of the work they are called on to perform. In a ball and socket joint, which, so far as this is concerned, may be regarded as a kind of universal hinge, the capsule is modified in the same manner. In the hip, where unyielding support in front is required, that part is so strong that, even in dislocation, it very rarely gives way ; behind, where there 14 Sprains ; their Consequences and Treatment. is but little strain, it is comparatively thin and weak. In the shoulder, everything- else is subordinated to accurate and rapid action in all directions. The capsule consequently is, with the exception of one part, so loose and long 1 that it only becomes tense when the angle of movement is extreme; the muscles here take the place of the ligaments almost entirely, and not only execute but also control and restrain the movements of the arm with a precision that would be impossible if it were dependent on passive and unyielding fibrous tissue. The Synovial Membrane. The cavity of a joint always contains a certain amount of an exceedingly viscid fluid, known as synovia. The quantity is very variable even in the same joint, but in general there is merely sufficient to moisten the surfaces that are in contact with each other, so as to avoid friction as far as possible. It is secreted by a delicate struct- ure known as the synovial membrane. This lines the interior of the fibrous capsule, and is prolonged into all the outlying pouches in connection with it, but does not extend, at least in the adult, over the layer of cartilage that covers the ends of the bones. Before birth an exceedingly delicate film of cells, without an}" fibres, may be found in this situation; but they are soon worn off, and do not reappear. Where this membrane is folded on itself, as, for example, at the attachment of the capsule to the bone, it is often thrown into folds, which, under some circumstances, are capable of assuming a very consider- able size. The inner surface is smooth and polished ; the other is continuous with the fibrous tissue of the ligaments, where they serve to enclose the joint; but between them, and in the intervals found here and there extending under muscles, it possesses a delicate wall of its own, formed of connective tissue, and connected to the structures round by a few loose and scat- tered fibres. This synovial membrane is in general regarded as a sepa- rate and distinct structure, found in those joints only in which there is considerable freedom of movement. In others, it is stated that an imperfect cavity is sometimes developed, but that it is never lined by a true synovial sac. This view is in- correct; neither the method of development nor the changes that take place in disease lend it any support. In reality, the synovial membrane is nothing more than the lining of the cavity, which is developed as the amount of movement in- ^Sprains; their Consequences and Treatment. 15 creases; and under similar conditions, structures indistin- guishable from synovia! sacs may be developed in any part of the body. In the centre of a joint the cells which fill up the space be- tween the bones break down, become liquid, and dissolve away; round the circumference they persist. The outermost, as already mentioned, are converted into fibrous tissues, and form the ligaments, or the capsule, as the case may be; the inner ones, those that immediately line the cavity, form the synovial membrane. The cartilage on the ends of the bones is not covered with it, or it is at most covered with a single layer of cells, because of the relation it bears to the cavity, and because there is no fibrous tissue developed on its surface. In the intervals between the ligaments, where there is nothing to protect the cavity of the joint, it is a little stronger than elsewhere, and may be called a membrane; but it is not an isolated or distinct structure here any more than it is else- where. It is continuous on either side with the neighboring ligaments; where it comes into contact with the cartilage it shades off into it, so that it is impossible to say where one commences and the other ends; and its outer surface is part of the loose and delicate connective tissue that fills in all the irregularities round joints, extends under the muscles and tendons, and forms a layer under the skin. Mutual Sympathy of all the Parts. Joints are commonly regarded as composed of many different structures, all of them separate and distinct from each other, with different and in- dependent functions. There are ligaments to hold the bones together; a sjmovial membrane to render the movements smooth; cartilages over the ends of the bones to lessen the impact of any shock; and round them, filling up all the inter- spaces, a quantity of loose and delicate connective tissue, con- taining the blood-vessels and nerves which supply the joint. This view may serve for the purposes of ordinarj 7 descriptive anatomy; but it gives an altogether wrong impression of the nature of the injury sustained when a joint is sprained, and of the causes of the complications and after-troubles that follow with such frequency. The bones that form a joint, no matter how many there may be, or how great may be the varieties of their shape, are surrounded and held together by connective tissue, which is structurally continuous with them. It bridges 1 6 Sprains ; their Consequences and Treatment. over the interval between them, fills up all the interstices left by the muscles and tendons, and forms an investment for these and every other structure near. One part, where there is much tension, becomes dense and unyielding, so that it is known as ligament; in another the cells undergo a process of liquefaction, and a cavity is formed ; the limiting wall of this is differentiated into a synovial sac, and a membrane more or less distinct is developed from it. The different structures lose all external resemblance to each other. What they do not lose is their relationship from their common descent. Throughout the whole of life the closest sympathy persists between them, so that it is impossible for any one of them to suffer by itself. It follows as a natural consequence from this that sprains can never be the simple things they are usually considered, or be confined to the mere stretching or tearing of an isolated ligament. The immediate effect of an accident may fall upon the ligaments, or it may not; it can never be limited to them. The capsule of the joint is opened up, the cartilages bruised, the muscles torn, the tendon sheaths strained, the interior filled with blood, and so much more ex- tra vasated into the tissues round that the strain may extend the whole way up a limb, and may not disappear for six weeks. Very often, in spite of the popular belief, the ligaments are the part that suffer least : they certainly never suffer alone. Even if by any chance they were the only structures hurt at the moment, it is impossible for the other tissues to remain unaffected during the changes attendant on their repair. A wheel or a band in a piece of machinery may be damaged and restored without interfering with the other parts. When a ligament is hurt a certain amount of blood escapes into the synovial sac and the spaces round ; all the vessels dilate; the synovial folds become swollen; the joint is tender to the touch; the temperature of the part is raised ; its movements are in- terfered with; even the external shape of the limb is altered. Nothing escapes ; every structure round participates more or less. The same is true of the later troubles that so frequently impair the freedom of movement in joints long after they have been sprained. The stiffness, for example, that is often laid to the credit of a contracted tendon, or shortened band, is never due to this alone ; nor is the sense of insecurity dependent en- Sprains ; their Consequences and Treatment. 17 tirely, or even to any extent, on the weakness of an injured lig-ament. It is only by taking- a wider and more comprehen- sive view of the structure of joints, and by regarding- them as organs of the body, wonderful in their complexity, that a true conception can be obtained of the nature of the damage they suffer in sprains, and of the method in which they should be treated, so as to avoid, as far as may be, the occurrence of permanent injury. CHAPTER II. CAUSE AND PREVENTION OF SPRAINS. WITHOUT going- so far as to say that sprained joints can be entirely prevented, there is no doubt that it is possible to avoid and guard against them to a very considerable degree. In some people they are particularly common; and so they are at certain times, and under certain conditions. Others escape in a manner that seems almost marvellous, and possess the power of using- their joints in a fashion that would be im- possible in the majority. The Condition of the Muscles. This depends mainly on the condition of the muscular system. The strength and se- curity of the articulations are assured in proportion to the perfection of its development. Sprains never occur unless the muscles are either weakened and tired out by prolonged ex- ertion, or are caught unawares by some sudden slip, before they can recover themselves. Astley Cooper said of disloca- tions that it was only possible for them to take place when the muscles were unprepared for resistance; otherwise the greatest force would hardly produce the effect. Without say- ing so much of sprains, there can be no question that such accidents rarely happen unless the muscles that safeguard the joints are taken by surprise. Ordinarily speaking, they are the result of a sudden twist, so rapid that recovery cannot take place in time, and naturally this is most likely to happen to those who have never accustomed their muscles to much exertion, or who, from fatigue, have lost that instinctive vigil- ance and power of recovery essential to the safety of a joint. This, among others, is one reason why sprains, especially of the knee and ankle, are so common among women, and those men who, in their youth, were distinguished for athletic feats. In the former, the muscles are insufficiently exercised, so that they never attain the vigilance and instantaneous power of response necessary to prevent the consequences of a Sprains ; tJieir Consequences and Treatment. 19 careless step; in the latter, with advancing- years and altered modes of life, the muscles fall out of training-, without its being- perceived, or perhaps sometimes without its being- acknowl- edged. Then some unusual effort, especially a prolonged one, that in days g-one by would have been accomplished easily, proves too much for their endurance under the altered condi- tions, and something- gives way. Unhappily, when this has taken place once, the joint often remains, as it were, a weak- ened spot, and there is always the possibility of the same thing- happening- again and again, with greater ease each time. The muscles are really part of the joint as much as the bones or the synovial membrane. It may be more convenient to describe them separately, but the function of a joint is movement, and in considering- the way in which sprains inter- fere with this, the muscles that execute and direct it are as much concerned as the ligaments, which have only the passive duty of checking it when it is excessive. This is true of all joints, but especially of those in which the freedom of move- ment is greatest, and which on that account are the most ex- posed to strains and injuries of like character. As Morris has pointed out, the strength of any single joint, and its power of resisting injury, are inversely proportioned to its freedom of mobility. In the more fixed joints, where there is only an indistinctly marked cavity in the centre of the fibre-cartilage, the muscles are short and broad, with much inelastic fibrous tissue in their composition, and often are so arranged with cross- running and interlacing fibres that while one bone is moving on the other it is held even more firmly in contact with it than when it is at rest. Where, on the other hand, the range of movement is extensive, the security of the joint is often dependent entirely on the muscles. In the shoulder, for example, there is a fibrous capsule surrounding the ends of the bones, and forming the apparent bond of union between them. But it is so loose, and has so little influence in controlling movements, that if the muscles are paralyzed the arm drops down for upwards of an inch. Here in particular, owing to the need of accuracy and delicacy, combined with strength and rapidity, the function of controlling the movements of the joint is assigned almost en- tirely to those structures which originate them. The muscles take the place of ligaments. 2O Sprains ; their Consequences and Treatment. When this occurs their shape and arrangement are modi- fied. They become divided, roughly speaking 1 , into two sets. Some are short and "broad, and immediately surround the joint. These maintain the proper degree of pressure between the bones, and keep the action smooth. Others are much longer, and are attached to distant points by means of rounded tendons, which lie in grooves lined by a delicate sheath. On these depend the vigor and rapidity of the movements. They differ greatly in size and direction, but the connection that exists between them and the joint is no less intimate; the same nerve supplies them both. They are really but different parts of the same mechanism, so closely united together by the bond of common descent, and so associated with each other by the identical nature of the nerve supply, that it is not possible for one of them to be injured and the rest escape. The same is true of the skin that covers them in and pro- tects them. This, too, is supplied by the same nerve, and when the joint or the muscles is injured cannot help being affected at the same time. Illustrations of this are of com- mon occurrence as the result of sprains. It has often been re- marked that after prolonged and severe exertion the skin over the insertion of the muscles, and in certain spots over joints, becomes exquisitely tender from its sympathy with the parts beneath. It does not arise from any irritation or inflamma- tion of the skin itself, for nothing has happened to affect it in any way. Yet the slightest touch gives rise to the feeling of actual pain. Firm pressure, on the other hand, relieves it, not, as is often said, because it is hysterical and imaginary, but because of the numbing effect of compression on the super- ficial cutaneous nerves. Plainly the skin, which is an exceed- ingly sensitive structure, is suffering in sympathy with the overworked organs it is intended to protect. The Muscles as Ligaments. The muscles, therefore, must be considered in a twofold relation to the joints. On the one hand they are the sole agents for executing movements; on the other, under all ordinary circumstances, they take the place usually assigned to ligaments, and act as the main safe- guard. So long as the action is confined within moderate limits the ligaments are entirely unconcerned ; they are merely passive bands of inelastic fibrous tissue, so loose as to have no restraining power until a certain angle is reached. Then they Sprains ; their Consequences and Treatment. 21 suddenly become tight, and bring- the movement to an abrupt conclusion. The muscles, on the other hand, are always tense, no matter what may be the position of the limb. No move- ment, not even the bending of a finger, is so simple that it can be carried out by the action of a single set; the opposing ones must always act with them, so that the movement may be even and steady, not disorderly at its commencement, or brought to a sudden standstill at its close. The firmness and security of the joints except such as the knee in all their positions are entirely due to the continuous steady contraction of opposing groups of muscles. They are the agents which prevent movement being carried too far, so that under or- dinary conditions strains do not fall on rigid and inelastic ligaments. When from fatigue or carelessness this does hap- pen, the ligament may be strong enough to resist, but more often especially in the joints with free movement it stretches or tears, and a sprain of greater or less severity is the result. Under these conditions the muscles sometimes suffer, while the ligaments escape. The injury may be immediate, or not show itself until some time has elapsed They may be torn or bruised by the violence with which the bones are wrenched apart; or what is, perhaps, more common, hurt themselves by the sudden and almost involuntary attempt at recovery when a slip is threatened. If they escape at the moment they may suffer even more seriously at a later period from wasting, rigidity, or degeneration, so that in severe cases they become converted into dense unyielding bands. This, perhaps, is not a common occurrence when recovery is rapid, though it is by no means unknown; when it is delayed, they rarely fail to show that they have undergone some kind of change, and that they are not so perfect as they were before. The Effects of Muscular Development. Besides, however, acting as a safeguard and protection against accidents of this nature, the muscular system is of great importance in another way. The degree of perfection to which joints attain and naturally they differ immensely in this respect in different in- dividuals is dependent entirely on the extent to which the muscular system is developed. Where the muscles are poor and feeble the joints are poor and feeble too, and are easily sprained. The ends of the bones, instead of being angular, with sharply-cut and well-defined 22 Sprains ; their Consequences and Treatment. edges, are smooth and rounded. The articular surfaces are faintly marked, so that they can glide on each other in irregu- lar and unusual directions; the capsule is loose and yielding, and the ligaments, without the assistance of the muscles, are unable to withstand the least strain, or even to maintain the normal relation of the two bones. The action of the joint is uncertain and often painful, and the loss of power is propor- tionate. In case of anj extra work the bony surfaces glide irregularly on each other, and move beyond their ordinary limit. The more often this takes place the more easy it is for it to happen again. Each time it is always carried a little farther than it was before, until at length, some day, one bony prominence is caught behind another over which it has slipped, or a tendon or disc of cartilage escapes from its bed, and the joint is locked. Pain and swelling rapidly follow. The patient may be able to restore things to their natural position at the first, but more often some assistance is required. The serious thing is that when this occurs, as it is wont to do more and more often, the joint never has time to recover its natural condition, and is left permanently damaged. The principle that the more a part is used, within, of course, rational limits, the more perfect it becomes, has long been recognized in the case of bones. The skeleton of the male is very different from that of the female ; the work is harder, and the bones become stronger. In the one they are solid, heavy, and exceedingly irregular, from the development of muscular ridges; in the other they are lighter altogether, and much more smooth and even. So with animals that have long been kept in confinement, the bones, contrasted with those of wild ones of the same species, scarcely admit of comparison, the difference is so great. It is the same with the muscles. As Humphry has pointed out, there is a difference almost of kind between the slender, compact frame and wiry, active muscular system of the thoroughbred, and the coarser, heavier, and more clumsy tissues of the cart-horse. What is true of the shafts and muscular eminences of bones is equally true of their articular ends, and of the rough surfaces to which ligaments are attached. Joints are well formed and secure from injury, so far as shape can make them, in proportion to the amount of their use and the perfection of the muscular system. Sprains ; their Consequences and Treatment. 23 Chronic Sprains. Such a condition as the one I have de- scribed above may be almost called a state of chronic sprain. So long- as it is slight it does not attract much attention. There are complaints of loss of power, and of twisting- or giv- ing- way, but, as a rule, the deformity is not conspicuous, and especially as it is most common in children, it is put down to what is called growing- pain, a name which has probably done as much harm as any other by the way in which it makes ligiit of what often is the commencement of a serious disease. When it is more severe, or when during- some unaccustomed effort the limb fails completely, the joint is generally said to be out. The pain is very severe; swelling- soon makes its ap- pearance, owing- partly to the unnatural position of the bones, partly to the effusion round ; and, owing- to the insecurity of the joint, the loss of power is so great that the patient often believes himself paralyzed. It is serious, not on account of the tearing- of the capsule or the injury to the parts around, but because the cause is such a persistent one, because the condition of thing's which has given rise to it is one that re- quires a long- and systematic course of treatment before it can be rectified. One of the earliest and most characteristic examples I have seen was in a young- girl who was broug-ht to me complaining of partial paralysis of the rig-ht arm, attended at times with attacks of severe pain. She was a tall, overgrown girl four- teen years of ag-e, employed as a nursemaid, having- to carry about a heavy child, and owing- to this condition of her arm, which had been coming- on grad ually for the last three or four months, had lost her situation. She was not aware of having sustained any single severe injury to her shoulder; but stated, of her own accord, that long before it reached its present state it was continually giving way, or, as she expressed it, coming out of joint. On comparing the two sides together, it was evi- dent that the muscles round the shoulder joint on the affected side were smaller than those on the other, though the differ- ence was not equally marked in all. The movements were limited to a great extent by the pain they occasioned, and the general muscular strength was decidedly below normal. The cause was apparent at once; there was a large amount of thickening over the point of the shoulder round the joint, that is to say, between the collar-bone and the shoulder-blade; and 24 Sprains ; their Consequences and Treatment, the bones were so loosely connected together that the end of one could easily be made to slip backward and forward over the end of the other. When the shoulder-blade was held in position by firm pressure from behind, the movements of the arm could be executed nearly as well as those of the opposite limb, and with nearly as much vigor, while the wasting 1 dimin- ished so much that evidently it was in the main apparent only. As soon as the pressure was taken off, the bone at once under- went considerable rotation, the upper border being 1 so much displaced that a deep hollow made its appearance behind the collar-bone, which slid in such a direction that the two com- pletely lost their normal relation to each other. The fact that the wasting almost disappeared, and that the movements could be executed with ease as soon as the shoulder-blade was fixed, quite negatived the idea of paralysis. The slight amount of real wasting, affecting only a few of the muscles, could easily be accounted for by the inflammation of and round the joint; wasting much more extensive than this sometimes under these circumstances comes on within a week. There was no history of any accident sufficiently severe to suggest the idea of a dislocation with rupture of the liga- ments; the onset of the mischief had been quite slow and gradual, though every now and then the pain which had, as usual, been called growing pain and the inconvenience had suddenly become worse. For the same reason it could hardly be termed a partial dislocation ; the capsule was not torn, and the whole thing had come on slowly and imperceptibly, so that the patient could assign no date at all for its first commence- ment. The characteristic features were the weak muscular development, the imperfection in the shape of the articular ends, and the loose yielding condition of the ligaments. So long as no extra strain fell on the joint, the muscles, weak and feeble as they were, were sufficient to maintain the surfaces in contact; a little extra work, slowly and gradually in this case, tiring out the muscles, allowed the strain to fall on the liga- ments, until, as ligaments always will when subjected to long- continued tension, they gradually stretched more and more, and became so loose that the end of one bone could slip back- ward and forward and ride over that of the other. A similar case, differing, however, in the joint affected, that between the collar-bone and the breast-bone, and in the fact Sprains ; their Consequences and Treatment. 25 that it was distinctly made worse by one rather severe strain, came under my notice almost the same day. The patient, who was also a girl, aged about 18 years, had suddenly felt a severe pain in this joint two days before as she was trying 1 to lift a heavy weight, and, of course, had been told the joint " was out." At the first glance this did not seem unlikely, for the inner extremity of the collar-bone was much too prominent ; but there was very little swelling or tenderness, and no bruis- ing whatever. On further inquiry, too, it was elicited from the patient that for some months past the arm had felt very weak and unsteady in its movements. Examination of the opposite joint showed that it was nearly in the same condi- tion, and, in fact, the bones on both sides were so loose that they could be pushed almost as far backward and forward as they could upward. Clearly, the ligaments were unusually lax, and two days before, when an unaccustomed strain fell on the right joint, it gave way, causing so much pain and incon- venience that the patient was compelled to seek advice. These two cases are, perhaps, somewhat exaggerated ex- amples, because in both the already loose condition of the liga- ments had been intensified by severe strains; the same state, however, exists independently of these, and no joint in the body is exempt. The shoulder, as might be imagined from the description already given, is peculiarly prone to suffer. If the joint is poorly developed, or the muscles on which it depends for its security are lax and feeble, it can readily be made to assume abnormal positions. Sometimes this occurs with any movement, more often only with certain definite actions; in one cas , a girl of 16, whom I watched for a long time, whenever in dressing of a morning she placed her hand on the back of her head in trying to arrange her hair, the upper end of the humerus slipped over the edge of its socket, and was caught there. At length she learned by a clever twisting action to bring it into its place again, and even grad- ually to avoid displacing it altogether. In the elbow joint, from the shape of the bones, this acci- dent can scarcely happen; but the same condition of things occurs. Examples may often be met with in which the fore- arm can, without any violence or pain, be bent back to an ab- normal extent on the arm; the ligaments in front are so loose that they do not check the movement sufficiently, and the 26 Sprains ; their Consequences and Treatment. bones so feebly developed that their projecting extremities do not come into contact with each other until the normal range is greatly exceeded. In the case of the lower jaw it has long been known. Hamilton described it as occurring in his own person, and, naturally, with the greatest possible accuracy. He has no- ticed, also, the curious circumstance that this displacement, when it does occur, is much more common in the morning than at any other time of day. Particularly at breakfast the lower jaw, owing to the looseness of the ligaments that should re- strict its action, is apt to become locked when the mouth is opened at all widely, and some manipulation is required to bring it back again. Whether the same thing can occur in connection with the hip is, I should think, very doubtful. I have seen one patient who could at will dislocate her thigh-bone by a peculiar twist- ing of the limb; but in the absence of any history that could be relied on, and as her other joints gave no sign, which they almost certainly would have done in such an extreme case, I should imagine that probably this condition had existed from birth, by virtue of some congenital defect. In the knee minor degrees of it are quite common, not only allowing abnormal movements of the leg upon the thigh, but also giving too wide a range of action to the semi-lunar cartilages in the interior of the joint, whereby, perhaps, at length is brought about the beginning of a most serious affection known as internal de- rangement. It is singular that this condition of the joints, which is very common in slighter degrees, and very striking in the exag- gerated form I have described above, should have attracted so little attention. Sir Astley Cooper has described it in the case of one joint. Hamilton mentions it from his own personal experience in another. Malgaigne gives a vague account of something similar, but although he regards it, quite correctly, as the consequence of debility, and often determined to one particular joint by a local trouble, such as a sprain, he does not appear to recognize it as a general condition, affecting many joints at one and the same time; and he fails altogether to separate it from cases in which the capsule or ligament have been weakened, or stretched by inflammation, or by the passive accumulation of fluid in their interior. It is even more Sprains; their Consequences and Treatment. 27 strange that he fails to appreciate the fact that the ligaments, though undoubtedly concerned in the production of this condi- tion, are in reality only passive agents, and not in any way the immediate cause. He states that it is due to an essential relaxation of the ligaments, though he fails to describe what this may be. In reality it is the muscular system that is at fault; for on this more than anything else depends the perfec- tion of the joints, and the strength and power of resistance of the ligaments. The secret of it all is to be found in the feebleness of the muscular system. In the first place the joints are weak, and the ligaments loose, because they have not been properly ex- ercised. Then the muscles are not equal to any amount of work. When a little extra labor falls on them (and very little is needed in cases such as these) they soon become fatigued; the joints lose their support, and either the already feeble liga- ments yield slowly and steadily, with a very considerable amount of pain, as ligaments always will yield when exposed to any severe strain; or else, owing to some sudden slip, the weight of the body falls on them before the muscles can save them, and some permanent injury is the result. It cannot be too clearly laid down that not only do the joints depend for their perfection on the degree of development of the muscles, but that, at any moment, the contraction of the muscles round a joint is as essential to its security as the ligaments, perhaps more so. If they yield, the ligaments will never hold for long. Effects of Age on Joints. One other feature in the con- struction of joints cannot be passed over in silence, as it helps to explain why sprains in some people are so liable to be fol- lowed by complications from which others are quite exempt. The joints are not alike at &ny two periods of life. It is ac- knowledged that they do not attain their highest stage of per- fection until adult years are reached, but even after this their most important features undergo continual modifications. In infancy, adult life, and old age there are vast degrees of differ- ence in their structure, due partly to the way in which they have been used, partly to the natural changes that take place in them as age advances, and partly to disease. Leaving aside for the present this last consideration, the differences that exist between the joints at various periods of life are most striking. In the infant the surfaces and edges 28 Sprains ; their Consequences and Treatment. of the cartilages are rounded and smooth, closely fitting 1 to- g-ether at the centre so as to leave between them merely a cleft, which widens a little, but very little, at the margin. The shape of the joint cavity is well defined, regular, and even. There are no outlying pouches or projecting fringes; every- thing is as simple as it can be. The fibrous capsule round presents- the same features. It is, it is true, a little stronger in one part than it is in another, but there are no great acces- sory bands of dense unyielding ligament. All is soft and deli- cate in structure, shading off imperceptibly into the surround- ing connective tissue, and what is, perhaps, the most important feature of all, exceedingly richly supplied with blood-vessels. In the adult these are confined almost entirely to two circles which surround the ends of the bones, where the capsule is attached, and send loops into the folds and fringes which abound there. In the child, and still more in the infant, not only are they larger and more numerous in proportion to the size of the parts, but they extend over the whole circumference, and are not limited to any single region. In consequence of this, when inflammation arises, no matter what may be the cause, its course is much more rapid, and the exudation of lymph infinitely more profuse. In children sprains are at- tended by an altogether disproportionate amount of swelling, and probably many of the complications that occur in them are due, not so much to inherited tendency as to the extraor- dinary richness of the blood supply, and the rapid and tumult- uous character of the tissue changes that take place under such conditions. All through life, not merely in youth, but even in old age, this undergoes continual change. The difference is not only one of size, but of structure, arrangement, and relation. The cartilage is replaced by bone, with the exception, as already mentioned, of the layer that directly lines the cavity. The edges become sharp and well defined, and the surfaces are no longer moulded accurately to each other. The capsule in- creases in strength and thickness. Where the strain is great the delicate connective tissue becomes dense and unyiel cling ligament; in other places it forms a close and even membrane round the central space. But these alterations, great as they are, are slight when compared with those of the synovial cav- ity and its delicate lining. This not only increases in size in Sprains ; their Consequences and Treatment. 29 proportion to the growth of the joint, but becomes greatly changed in shape. Pouches are thrown out round the bony projections and into the weaker parts of the capsule until in outline it bears scarcely any resemblance to what it was at birth. Accessory spaces, known as bursse, are developed wherever there is friction, under tendons, for example, or be- tween bones and muscles. These differ in each individual both as regards shape and position. As age advances the}- become larger and larger, until at length they encroach to such an extent on the lining membrane of the joint cavity that the intervening partition gives way, and a communication be- tween them is established by an opening which grows wider and wider each year. While this is going on the surface of the lining membrane does not lag behind. It does not remain smooth and regular, merely folded on itself where it is reflected on the bones. Pro- jections grow into the cavity from all sides. Some spring up from the spot where the capsule is attached to the bones, so that these are surrounded by a ring of fringing growths. Others project inward from the ridges and inequalities of the surface or the margins of the openings already mentioned. Some are short and smooth, others long and branched. In some the end expands into a rounded body containing carti- lage corpuscles, while the neck grows thinner and thinner until it gives way and allows it to drop off. Many of them contain loops of vessels, especial^ when they grow from the region of the vascular circles; other are merely masses of fibrous tissue. There may be only a few scattered about, or the whole interior, especially if examined under water, may be covered with a dense shaggy coating under which it is no longer possible to recognize the polished regular surface met with in youth and childhood. It is often difficult to .tell how far these changes are the result of age, or to what extent they are the direct consequences of disease; the two so often go together hand in hand. The effect is that in no two persons are the joints ever alike; and the older thej 7 become, the more work and the harder the work they are called upon to do, the greater the changes and the wider the difference, until at length it is scarcely possible to find a resemblance except in the broad general features of construction. OHAPTEE III. DIAGNOSIS. IT is not often that there is much difficulty in the diagnosis of a sprain, particularly if the joint is a superficial one, like the ankle or the knee. The nature of the accident, the sudden onset and peculiar character of the pain, the rapid swelling- of the part, and the helplessness of the limh, are in general quite sufficient to convince the patient of the misfortune that has befallen him. But as, short of actual dislocation, nearly every kind of injury that can involve either a joint or the tissues in its immediate neighborhood, is called a sprain, this is scarcely sufficiently definite. In no other kind of accident do precision and exactness of diagnosis repay more thoroughly the pain and trouble of careful examination; nowhere is it more essen- tial to form a definite conclusion as early as possible, not only of the kind of hurt sustained, but of its extent and degree. Even then it often happens that constitutional peculiarities, or other agencies less easily controlled, assert their influence, and seriously complicate the progress of the case. Dislocations, fractures in the neighborhood of joints, and, in the case of children, separation of one of the growing ends of the bones, present the greatest amount of difficulty. In connection with this, there are one or two points which it is advisable to bear in mind. In the first place, in many joints, and particularly in those in which, like the elbow, complicated accidents are of common occurrence, an enormous amount of swelling sets in with such rapidity that all the prominences by which the relative position of the bones is ascertained are buried and lost in a very short time. Consequently, if the diagnosis is not made at once, immediately after the accident, it is necessary either to put the patient under an anaesthetic or to wait without a definite opinion for days, perhaps even for weeks, until the swelling subsides. The importance of this is so great that, especially at the present day, there ought to Sprains ; their Consequences and Treatment. 31 be no hesitation about the administration of an anaesthetic. In the case of children, it is often impossible to form an opinion without ; and even when it is, the risk is so exceedingiy slight, the relief from pain so great, and the advantages of being- able to examine the joint thoroughly without any muscular rigid- ity, and to apply the first dressings quietly and systematically, so immense, that they ought to be made use of where there is the least occasion. Nothing is more common than to meet with cases in which, from neglect of this precaution, because the first examination could not be thorough, joints have re- mained stiff or imperfect in their action throughout the greater part of life. Further, if there is the slightest question as to the nature of the injury, whether it is a fracture involving a joint, or a sprain, the patient must always be given the benefit of the doubt, and the injury treated as if it were the more serious of the two, with this precaution, that passive motion must be re- sorted to, and the joint thoroughly worked at a much earlier period than it would be in the case of a simple uncomplicated fracture. It is probable that sprains of the ankle are very frequently confused with fractures of the small bone of the leg, and even with Pott's fracture without displacement of the parts; but as the immediate method of treatment adopted in these instances need not differ materially, no ill result follows, provided passive motion is adopted in time. Stiff joints, whether they are the result of fractures or of sprains, result most often from retaining the part immovable in a fixed ap- paratus for weeks together. There is one further caution which it is necessary to ob- serve, one that was originally suggested by Nelaton. It some- times happens that, even when only a single joint is complained of, one or more of the others in the same limb has sustained some hurt, though of less severity. Consequently it is as well, when examining a sprained limb, always to commence by in- vestigating the movements of the joints which the patient declares not to have been hurt ; otherwise they may easily be overlooked, and some time later an aggravating degree of stiffness found that might easily have been avoided by the ex- ercise of a little precaution. There is this further advantage, though it may not be worth much, that the patient, when the joint that really has been injured is taken in hand, knows 32 Sprains ; their Consequences and Treatment. what is going- to be done, and is less apprehensive of any rough movement. The same thing may happen when one of the bones is broken: a sprain and a fracture may occur in the same limb from the same accident, and owing to the great amount of attention paid to the one, the other may be altogether over- looked. Dr. Bennett, of Dublin, narrates the case of a man who slipped as he was carrying a heavy sack down a sloping plank. His foot was suddenly checked in its slide by some irregularity, and he fell, conscious at the time that something had given way in his leg. Admitted into hospital, as he was unable to bear any weight on his limb, he presented the or dinary features of sprained ankle, without any sign of fract- ure. The case was treated as a severe sprain, and attracted but little attention for some days, until it was noticed that there were some signs of bruising on the upper part of the leg. On examination, the localized pain, and the crepitus character- istic of fracture, left no room for doubt as to the diagnosis. In addition to his sprain, the small bone of the leg had given way a long distance from the ankle, though he was certain he had not struck it in his fall. The amount of displacement of the broken ends was very slight; the line of fracture was oblique; and there is no doubt it might easily have been passed over altogether. Probably, as Dr. Bennett suggests, accidents of this kind are much more common than is usually supposed. Swelling. Much of the difficulty of diagnosis arises from the variety of the symptoms presented by sprains; they are scarcely alike in any two cases. In hinge joints, for example, the mischief falls on the ligaments which oppose a twisting force; in a ball and socket arrangement, the muscles, as a rule, are the greatest sufferers. Sometimes, especially when it is due to haemorrhage, the swelling makes its appearance at once, and accurately reproduces the shape of the synovial sac. At others the bursaB or the tendon sheaths in the neighbor- hood are distended, so that this is quite concealed, or there are extensive extravasations into the loose cellular spaces un- derneath the skin and between the muscles. Or, again, the swelling may commence slowly and gradually, twelve, or even twenty-four hours after the injury, and be smooth and uni- form in outline from the very first, owing to the effusion into the soft tissue round as well as into the joint itself. Sprains ; their Consequences and Treatment. 33 Very often it is most distinct over the course of the mus- cles and tendons. The skin, for example, on the outer side of the forearm is raised and puffy over the insertion of the pro- nator radii teres, or there is a long 1 , low, rounded swelling- on the back of the wrist, running- obliquely across the joint over the course of the extensor muscles of the thumb. It is quite soft so soft, indeed, that it can often be appreciated better by the eye than by the finger never very great, because there is no cavity of any size in which fluid can collect, but exceed- ingly tender when touched. Sometimes, instead of the bony prominences being- partly buried by the collection of lymph round and between them, the reverse of this is the case. They are increased in size, and stand out under the skin in such a way that there may be some apparent ground for the common conclusion that the joint is out. In the wrist and hand this is a very frequent mistake, and it really is difficult sometimes, when one of these points is projecting beneath the skin, to prove that the bone has not slipped out of its place and been dislocated. The styloid process of the ulna on the inner side of the wrist is a favorite spot for this. It is often unduly prominent after an attack of gout or rheumatism, and, even when it is certain there has been no injury, it is frequently described as being- out. So with the base of the metacarpal bone of the middle finger, which, when the wrist is strongly bent, raises up the skin on the back joint. This often forms a projection, especially in gouty people, varying 1 in size from time to time, and occasionally appears quite suddenly after even slight ex- ertion. Probably it is due to a strain of the tendon attached to this point, and to the amount of effusion thrown out round the bone, but it is nearly always asserted that something is out of joint. Other parts of the body are not so liable to mistakes of this kind, in all probability because they are not exposed to such continual and minute examination. In the knee and elbow, even, considerable differences are not noticed unless they have appeared suddenly. Natural projections may in- crease in size, fresh ones may form, or what is perhaps more perplexing still, small ganglions may develop in such places as the outer side of the knee joint, just below the level of the knee cap, and at the same time there may be real impairment 34 Sprains ; their Consequences and Treatment. of mobility and strength, but unless this happens suddenly, or, what is far more common, is noticed suddenly, little atten- tion is paid to it. When there has been a recent accident the diagnosis is sometimes very difficult, and requires the greatest care. Staining. Valuable information may be gained sometimes from the place at which the bruising first shows itself. Blood effused deep down in a limb, as, for example, between the superficial and deep muscles of the calf of the leg," or in the groin, always follows certain well-defined routes, being guided by the anatomical structure and the arrangement of the sheets of fascia. When the limb is bandaged it is often driven great distances by the pressure before it can reach the surface. Sometimes its distribution is very peculiar. I have seen several instances in which, after a severe injury to the deeper parts of the hand, dark purple crescents caused by blood- staining made their appearance between each of the fingers, just above the web where they divide. Owing to the attach- ment of the palmar fascia, the coloring matter had soaked through to the skin in a regular and symmetrical pattern. Pain. The character of the pain, if the patient can describe it, may be of great help. When the strain falls on the liga- ments it is usually said to be sickening, and a patient who has suffered from it once rarely fails to recognize it a second time. It is very sudden, often so severe as to cause the sufferer to faint, and then gradually, if the joint is kept quiet, passes off again, leaving an aching deadness of the limb, but coming back in an aggravated form on the least attempt at move- ment. This is well marked when a tendon, or one of the in- ternal structures of a joint, slips from its place. So long as the part is kept perfectly still, even if the position is abnormal, the pain is only moderate in severity; it becomes worse and worse as the structure shifts from side to side, until just as it slips back into its bed it is as severe as ever; then it suddenly ceases. The cause at first is the forcible stretching of the ligaments; the later aching seems, in the majority of instances, to be proportionate to, and therefore probably dependent on, the amount of distention of the joint. Tenderness. Muscular strains, on the other hand, are dis- tinguished by a peculiar sensitiveness of skin, most marked over the points of attachment to the bones or tendons. These, Sprains; their Consequences and Treatment. 35 as a rule, are the weakest spots, where they give way first. If they are even touched the patient shrinks away with the pain ; hut curiously enough, very often steady, gentle pressure is well borne. The same thing happens when the muscles are overworked, especially during convalescence. At this time the exertion even of sitting upright is sufficient, because the work, trivial though it is, is too much for the muscles in their weakened state. When a muscle is torn across, either wholly or partially, as in some cases of lawn-tennis leg, the symptoms are of a totally different character. There is a sudden sharp pain, like that of a blow with a whip or a cricket ball, so that the patient turns round to see who has struck him, before he is aware that anything has given way; and then, as the swelling begins, this is followed by a feeling of stiffness and soreness, severe even when the limb is at rest, but so much worse when an at- tempt is made to use it, that the patient often can hardly be induced to try. Dislocation of a muscle is not unlike this. There is the same sudden pain, and the part is held fixed in the position of the moment, no matter how inconvenient it may be. If, for example, one of the muscular slips in the neck is displaced by some irregular movement, the head is kept rigid in the posi- tion into which it was twisted. It is not possible for a time to bring it straight again, much less to make it face in the opposite direction ; only after the first pain has subsided can it be brought round by slow degrees. Even then, as soon as the attention is withdrawn, it quietly, but surely, moves back so long as the displacement is uncorrected. When the parts are restored there is nothing but a sensation of soreness, w r ith a tender spot or line in the neck corresponding to the particu- lar slip displaced. These tender spots often afford valuable information. They may persist long after apparent recovery has taken place, and they generally point to something which is not quite restored. In a sprained ankle, for example, if one of the lateral ligaments has given way, or has torn off a scale from the bone to which it is attached, that spot remains tender for weeks after. Sometimes they indicate the presence of adhesions, or of tough , contracted parts of the capsule; occasionally they correspond to the situation of synovial fringes, or foreign bodies, or to the 36 Sprains; their Consequences and Treatment. places at which the nerves enter the joint; and in one or two instances I have known them caused by extravasation in the substance of the capsule itself. Allowance must be made for those that are normally pres- ent when a joint is hurt. What they are caused by is not always certain, but as a rule they correspond to places where the capsule is thin and flexible, and not far removed from the surface, so that pressure falls on it directly. However this may be, they are so constant and definite that it is scarcely possible to mistake them. There is one, for example, nearly always present on the inner side of the knee-cap, about the middle of the joint; in the hip it lies behind the projection of the trochanter, and sometimes there is one also on the inner side. In the ankle they are not so marked, but there is very generally one on the front of the joint, rather to the outer side of the middle line. These are present with such regularity that they must almost be called normal. When other more unusual ones are found there is some additional reason to account for them. Sprains and Dislocations the Elbow in Children. Sprains and dislocations are sometimes very confusing, even without taking 1 into consideration the popular view that some- thing is out of joint in every sprain that does not get well at once. One instance in which there is great difficulty in dis- tinguishing them has been mentioned elsewhere, and it would be easy to multiply them. There is, for example, a peculiar injury about the elbow, only met with in children, concerning the nature of which there is still very considerable doubt. It is caused by the way in which they are swung round by the hands, or lifted across a road; and is rarely seen immediately, for though the child cries out with the pain, there is no dis- tinct or objective sign of anything wrong. Then it is noticed that the arm is not used as freely as the other ; that the child always cries when it is touched ; and that it is held constantly in one position, the elbow slightly bent, and the palm of the hand looking downwards. Now, certainly, in the majority of instances the seat of the mischief is in the elbow joint (J. Hutchinson, Jun., "Annals of Surgery," 1885) ; and it is highly probable that it is due to one of the bones of the forearm, on which nearly all the weight falls, slipping out from under the ligamentous collar which holds it in its place. But this view Sprains; their Consequences and Treatment. 37 is not by any means universally held; others, describing" the same accident, produced in the same way, causing- the same symptoms, and, more than all, cured by the same manipula- tion, have assigned it to a totally different joint, the wrist. It is even mistaken for fracture sometimes, for a very sim- ple but altogether insufficient reason. If the elbow is held firmly with one hand, while the forearm is made to rotate slowly from side to side, there is a clicking- or snapping sensa- tion, perceptible both to the ear and the touch. Then some- thing- is felt to slip, and in g-eneral free use of the joint returns immediately. But sometimes this is not so easy; reduction does not take place at once; the peculiar sensation continues, and may even become more plain, until it is really difficult to distinguish it from the crepitus of fracture. It is needless to remark that whatever may be the actual nature of the hurt sustained, it can scarcely be this. If the displacement is recti- fied, and the arm kept quiet for a day or two, recovery is nearly always complete and thorough, which, under such con- ditions, would, of course be quite impossible. These cases are of everyday occurrence; though there may be minute points of difference, they resemble each other in all important features; the anatomy of the part is thoroughly well-known; the way in which the mischief is produced can generally be ascertained; and there is nothing mysterious, or even unusual, in the manipulation by which the parts are re- stored. Yet in spite of all this, not only is the actual nature of the injury doubtful, but even its locality is uncertain. When there is no history to be obtained, or only one that is confusing and misleading, and when the limb is stout and shapeless, or so much swollen that nothing can be definitely felt, the diffi- culty of forming an exact opinion, of making absolutely cer- tain at once that the joint is not dislocated or the bones broken, may be easily imagined. The close resemblance that exists between many disloca- tions and some forms of sprains ceases to be astonishing if it is remembered that, as Vidal de Cassis pointed out, they are really the same thing, only that in the case of the former re- duction has taken place spontaneously. In the one the ar- ticular ends, which at the moment of the accident are wrenched apart, slip back again into their natural position of their own accord ; in the other they slip still further aside. 38 Sprains ; their Consequences and Treatment. Sprains and Fractures. Ordinarily speaking there is not much difficulty in distinguishing sprains from fractures. One may easily be overlooked when both are present at the same time, especially if they occur, as they easily may, at the same spot ; but in other cases the signs are usually distinctive. The rough grating sensation when two broken ends rub against each other, the undue mobility, deformity, and pain present in most cases of fracture, are nearly always sufficient, though, as will be described later, some of these signs may be imitated exceedingly well by other conditions. If, however, the bones are so driven into each other by the violence of the accident that there is no undue mobility, especially if in addition the line of fracture runs through that part of the bone which lies immediately inside the capsule of the joint, it is not always easy to make a distinction. In the case of the hip this is well known, but accidents of a similar description, with or without impaction, are met with sometimes in other joints as well. Sprain Fractures of the Thumb. The thumb, for exam- ple, is liable to a peculiar form of injury, the real nature of which has only recently been explained. It follows in general a severe strain. The ball of the thumb swells up at once, and all power of bending it into the palm of the hand, or bringing it towards the other fingers, is lost. On the back of the bone, just where it joins the wrist, there is a distinct projection, not nearly so large as it would be if the joint were out, and recti- fied at once by pressure, only as soon as the pressure is re- moved it returns again, with a visible and painful jerk. If the two hands are compared together the length of the bones corresponds exactly, so that it does not look like a fracture; it cannot be a complete dislocation, and a partial one from the structure of the joint is impossible. In reality the injury partakes of the nature of both. There is an oblique fracture through the base of the bone, where it joins the wrist, splitting off that part which lies deeply buried under the muscles of the ball. It does not involve the back of the bone, so that the measurements are unaltered, but oAving to its carrying away with it the projection on the palmar surface that serves to make the joint secure, the rest of the bone slips back and sticks up under the skin. The crepitus, when pressure is made from front to back on the ball of the thumb, and the broken Sprains ; their Consequences and Treatment. 39 surfaces are rubbed together, can be felt quite easily, and the pain is greatly increased thereby. The ultimate deformity, if the injury is not diagnosed, is not so serious as might be imagined, but the movement of the joint is interfered with for a considerable length of time. CHAPTER IV. NATURE OF THE INJURY. SPRAINS differ a great deal both in the nature and extent of the injury. Sometimes it appears to be quite trivial ; there is merely the slipping 4 of a disc of cartilage from between two bones, or the displacement of a tendon from its groove; some- times everything- that holds the two joint surfaces together, with the exception of the skin, is torn and lacerated as it is in a dislocation. In many cases the injury is really as great: the bones are wrenched apart from each other at the moment of the accident, only instead of being caught and held, as they are in a dislocation, they fall back again of themselves into their natural position. Such accidents are always called sprains; but the tissues suffer as much as if the joint had really been put out. The extent to which the tissues are torn at the moment is not the only thing that has to be taken into consideration. The symptoms and the after consequences are often most seri- ous when this is apparently but slight; and the liability to in- flammation, and other troubles, depends a great deal more on the constitution of the patient, and the way in which the sprained joint is treated, than on the number or size of the structures that are torn. So long as the natural process of healing is still in its full vigor, as in children and young adults, injuries, no matter how serious they are, are repaired without the least difficulty. The treatment must be well planned, it is true, and thoroughly carried out; proper care must be taken that the parts are not subjected to too severe a strain before they can stand it; but if this is done, after consequences of any kind are the exception. Unhappily as time goes on the effects of age and of constitutional frailties become so power- ful that in many cases, in spite of every care, a comparatively trivial injury often leads to the most serious results, and re- Sprains ; their Consequences and Treatment. 41 covery is delayed indefinitely, or remains imperfect perhaps for the rest of life. Opportunities for examining 1 joints shortly after they have been sprained are not very common, though they occur some- times when a patient has received other and more serious dam- age in the same accident. By taking advantage of these a fair amount of information has been obtained with regard to ordinary cases ; and the results have been confirmed by Bon- net, of Lyons, and others, who have made use of other methods. Many special sprains, however, such, for example, as the in- ternal derangement of the knee-joint, first described by Hey, are still involved in a certain amount of obscurity. They are not uncommon ; for years past they have attracted an unusual amount of attention from the inconvenience they cause, and the striking character of the symptoms that attend them ; but the joints in which they occur are so complicated, and oppor- tunities for examining them so rare, that there is not as yet any settled opinion as to what the nature of the accident may be. It does not seem unlikely that the actual displacement varies in different cases, even though the external symptoms are to all appearance the same. Generally speaking, the tissues on one side of a joint are overstretched and torn; those on the other compressed and crushed together; but there is always so much twisting, and such a difference in the strength and power of resistance of the various structures, that unless the part is examined with the greatest care it is almost impossible to say what actually has given way. In every case no pains should be spared to find out the whole of the mischief with as little delay as possi- ble. There are many instances on record in which delayed convalescence has been due solely to the fact that a displaced tendon or other structure has not been recognized sufficiently early. The difficulty increases with every minute. Immedi- ately after a sprain, before the position of the parts has been altered by attempts at movement, or concealed by swelling, the nature of the displacement may often be recognized with- out much trouble. But if the chance is lost, the part begins to throb with pain, swelling sets in and obscures everything, and it is often necessary either to place the patient under an anaesthetic or to wait until the extravasation a ad oedema have been dispersed. 42 Sprains ; their Consequences and Treatment, Haemorrhage into the Sac. Most of the swelling that makes its appearance immediately is due to the blood that pours out from the torn vessels. The central cavity of the joint becomes distended with fluid, which varies in character and amount according" to the number and size of the vessels in the injured part, and the length of time that has elapsed since the accident. If the swelling reaches its maximum within the first few hours, it is probably due mainly to blood ; if twenty-four hours pass by before this, there is a large pro- portion of lymph mixed with it, and, at the same time, if the joint is superficial, some heat and redness of skin. The amount is very variable; sometimes it is not easy to detect any in- crease at all; at others, especially if no steps have been taken to check it, the distention is so great that the outline of the synovial sac may be traced distinctly beneath the skin. The delicate structures lining the cavity are torn and bruised, and the vessels continue to bleed until the contraction of their walls and the pressure of the fluid accumulating round them stops the flow. Probably the blood soon coagulates, as it does when extravasated into other tissues of the body; and at a somewhat variable period becomes liquid again. At least, if a joint is tapped or aspirated a few days after a severe sprain, it is found to contain a fluid, which, though it still reddens on exposure to air, differs from blood -in color, and in being turbid from floating debris. If left to itself, the quantity diminishes, and it undergoes other changes. The coloring matter slowly soaks into the tissues round, so that they remain deeply stained for weeks; the floating fragments become finer and finer, until they, too, disappear; and at length, though the amount re- mains excessive for a considerable time, it assumes again the character of the natural synovial fluid. The rent in the capsule may be almost imperceptible, merely a superficial line, extending across part of the cavity, and only marked by an uneven band of discoloration; or it may stretch right across from one side to the other, and open up the cellu- lar spaces round. It is especially liable to give way along the line of its attachment to the bone, and as this is where the blood-vessels are largest and most abundant it accounts in some measure for the amount of the haemorrhage. At this point there is a considerable thickness of soft loose tissue with little resisting power, and the fibres are more widely spread Sprains ; their Consequences and Treatment. 43 out and separated from each other than they are elsewhere, so that when a strain falls on them it attacks them, as it were, in detail, and easily overcomes them. It is very unusual not to find some evidence of violence, some staining- or reddening 1 at this point, after a joint has been sprained. Hcemorrhage in the Synovial Wall. The extravasation is, however, not limited to the interior. If the cavity is opened there are patches of it, apparently adherent to the inner wall, but really situated within its substance, covered over by so delicate a film of tissue that they can be plainly seen through it. Most of these disappear at length. They merely leave a thickened and discolored spot, which, as a rule, is well out of the way, and causes no inconvenience. If, however, they occur in a part of the joint where the lining- membrane is loose and thrown into folds when at rest, or where there are many fringes and outgrowths well protected from pressure, as round the neck of a bone, they sometimes lead to great annoyance. A hard, unyielding patch is formed in the smooth and supple wall; its flexibility is lost, and it cannot yield itself kindly to the movements of the joint, but drags on the other parts, and :.cts as a continual source of irritation and pain. These changes are not confined to sprains; -they occur after other injuries with almost equal frequency, and may always be suspected when, long after an accident, some particular or unusual spot remains tender, or one special movement is lim- ited in extent. The}- are particularly common in the deeper layers. The soft cellular pads that are developed in and round joints, for the purpose of filling- up spaces that vary in size with every movement, are generally deeply stained with blood. If this is absorbed again no ill result follows; but it often hap- pens, from the soft and yielding- nature of the tissues at these places, and from the way in which they are protected from pressure, that when a joint is kept at rest in one position this is never thoroughly carried out. The blood remains for a long time without changing, and then slowly becomes organized into a dense, unyielding mass. The pad which was intended to give way before the faintest pressure, and accommodate itself to every change of position, becomes hard and dense, and moulded to one form. So long as the limb remains at rest it is fairly comfortable; as soon as it is moved there is pain, because the pressure is no longer distributed evenly over the whole surface. 44 Sprains ; their Consequences and Treatment. Bursce. Changes of a similar character are very prone to occur where there are spaces near joints, in which blood or other fluids collect after injuries. They may be bursse or mere interspaces in the cellular tissue, without any well- marked limit; some are definite in shape and position, exist- ing 1 , at least in adults, in all alike; but many are accessory, developed here and there by the accidental friction of one structure on another, and, therefore, differing in size and shape and position in each individual. Whatever they are, they act as receptacles for the blood which is extravasated into the tissues after sprains and other injuries. It collects in them and distends them, lining their interior with a layer of false membrane, which slowly becomes organized and makes their wall dense and hard. Then they become tender and painful; their surfaces are roughened and irregular; they obstruct in- stead of assisting the movement of one part on another; and often, by inducing the patient to keep the part at rest, they lead to other changes, the importance of which is altogether out of proportion to the severity of the original injury. Some of these bursal swellings are very perplexing. In many cases where there is a large cavity overlying a joint it is very difficult to tell whether the fluid is really in the synovial sac of the joint or outside it. It may reproduce the shape ex- actly, and by its tension prevent the muscles from contracting as much as if the capsule itself were distended. In others, especially when the swelling is recent, and there is something firm behind, such as a bone or the wall of the chest, the imitation of a fracture is surprisingly good. There is a sensation of crackling, when the part is handled, closely similar to that produced by rubbing together the two ends of a broken bone. It is really due to the dense fluid being pressed through the mesh work of connective-tissue interspaces which make up the interior of most of these; and it may nearly always be distinguished (independently of the absence of the other signs of fracture) by the difficulty there is in eliciting it a second time, until either the fluid is driven back again or some more allowed to accumulate. There is no difficulty in feeling it once, but it is very hard to demonstrate it to another person. When extravasated blood collects in the space between the shoulder-blade and the back the sensation is most deceptive. Sprains ; their Consequences and Treatment. 45 I have known many instances in which a mistake has been made through relying on this, fractures of various parts of bone having- been diagnosed, in spite of the absence of displace- ment and of tenderness on pressure. This occurs, too, in other situations. In one case in particular the patient, who had on a previous occasion suffered from several fractures in different parts of his bod}-, was so firmly convinced that his collar-bone was broken that nothing could make him believe the contrary. He had sustained, certainly, a severe fall on his shoulder, and was badly bruised; there was great difficulty in raising his arm from the side, and the whole region was much swollen; but there was no displacement of any kind, and the tenderness was general, not limited to any one definite spot, as it would have been in the case of a fracture. On manipulation, how- ever, the most distinct crepitus would be obtained, especially when the arm was lifted up, and the shoulder grasped firmly from before backward by the finger and thumb; and it was so definite in character, and so perceptible to the patient, that he was absolutely sure that it came from his collar-bone. Not until ten days had passed, when he could use his limb freely in all directions without pain, would he admit that the fract- ure (if it was one) had united very much more rapidly than those he had sustained on a previous occasion. In this case there was undoubtedly a large extravasation of blood into the bursa which covers in the shoulder joint. Very likely its walls were torn, or crushed and bruised with some of the muscular fibres lying over it. Raising the arm pressed its sides together, so that the fluid was driven from one part to another, and squeezed among the irregular meshes that lined the interior. Later on this was absorbed; the staining made its appearance in the usual situation, under the borders of the deltoid, and as there was no permanent thick- ening or rigidity of the walls, movement was completely re- gained. All cases are not so fortunate. It is not uncommon to find the interior of this bursa lined in all directions with shaggy villous projections, hanging down in the cavity, the result of repeated injury or inflammation, and the cause of constant inconvenience and even pain. The Ligaments. The extent to which the ligaments are injured varies quite as much. It is no uncommon thing to find the strongest in the body, such as the internal lateral 46 Sprains; their Consequences and Treatment. ligament of the knee or ankle, completely torn across, and the joint as full of blood as it can be; or, on the other hand, there may be scarcely a bruise or tear. They are really part of the capsule uniting tog-ether the ends of the bones. The structure is the same in all essential particulars, and they are practically continuous; only the arrangement is different; in the one, the fibres are scanty and weak, with many and large inter-flbrillar spaces; in the other, they are arranged in closely woven bun- dles, parallel to each other, and so tense as scarcely to admit of any elongation by sudden violence. They may tear, es- pecially small portions of them here and there, so that the whole thickness is not broken across at any one spot; but they will not stretch. It is true that under certain conditions they do become elongated, but this only happens when the strain is continuous, and lasts for some considerable time. A slight degree of inflammation sets in then, and under its influence the fibrils soften until they yield Sometimes ligaments give way in the middle, but it is more common for them to separate from the bone, or to wrench from it a small thin scale corresponding to their attachment. This is due in part to the arrangement of their fibres. In the centre they are woven closely together, and form a rounded bundle of great strength; at the ends they spread out like a fan, so as to secure a wider attachment. By this their mutual support is lost, and the course of the fibres is altered, so that the direction of the strain no longer coincides equally well with that of all the strands. Owing to this they give way much more easily. A ligament that can resist successfully a straight pull of great violence yields at once to a twisting force of much less severity, because this falls on the fibres unequally, one by one, and tears them from their attachment. Intra-articular Ligaments. Some of the structures that lie in the interior of joints occasionally suffer in a peculiar manner. Inter-osseous ligaments, formed of very short nu- merous bands of fibres connecting immediately two roughened bony surfaces, rarely give way, owing to their great strength, the bone yielding instead; but the discs of nbro-cartilage, which are interposed in places between the bones for the pur- pose of deepening the sockets, and modifying the effect of shocks, are very liable to suffer. Sometimes they are bruised or crushed ; more often they are torn from their attachments Sprains ; their Consequences and Treatment. 47 and displaced, so that they interfere with the working of the joint. Or, without being- actually separated, they may be so stretched that the result is much the same. This is best known in the knee; in other joints in which discs of this kind are found they are so much smaller and so firmly fixed that they rarely give rise to any inconvenience. In the knee they are very large; their normal range of movement is very con- siderable, and they are so loosely held that displacement is not only easy, but, when it has once been produced (owing to the feebleness with which repair takes place), is always liable to occur again. The Knee. I am not aware that there has ever been an opportunity for examining the interior of a knee joint shortly after this had happened for the first time, and before the disc has been replaced. Indeed, from the nature of the accident, it is scarcely likely there could be such, except under the strang- est coincidence; but on several occasions the joint has been opened and the displacement verified after it has occurred re- peatedly. And often the patient is aware of a projection from the side of the knee, caused by the displaced disc. There is, therefore, no question as to the nature of the accident, but, as has been already mentioned, it is by no means certain that this explanation serves for all the various forms of internal derangement that have been described, even when full allow- ance is made for the different directions in which it may take place. The Fingers. The finger joints, again, are the seat of a peculiar kind of injury somewhat similar to this. They all of them belong to the class of hinge-joints, admitting free move- ment so far as flexion is concerned, but exceedingly little in any other direction. On the under surface of each there is a plate of fibro-cartilage, similar in structure to the discs hi the knee joint, and, like them, helping to deepen the socket hi which the head of one bone rotates. In fact, this is the chief bond of union between the bones, but while it is so firmly united to one that it is almost impossible to tear it off with any reason- able degree of force, the fibrous tissue that binds it to the other is soft and flexible, so as not to interfere unduly with the action of the joint. Sometimes it happens in severe wrenches, especially when the finger is forced backward, that this plate of cartilage is torn from its attachment, and slips 48 Sprains; their Consequences and Treatment. up between the bones, so that when the force is past they can- not resume their natural position. Mitchell Banks has shown how this occurs in the joint be- tween the index finger and the hand, in which it is most com- mon; and I have met with several instances, not only there, but in other joints also. It is an exceedingly painful accident, often causing fainting and sickness. The deformity is very conspicuous, especially in the back of the joint, though it is not so great as that of a true dislocation or when a bone is broken. The finger is kept slightly bent. By using the other hand the patient can move it through a considerable angle, but he can- not either straighten it out or bend it thoroughly into the palm. No amount of force produces any effect in the displacement; it is due to the cartilage which has slipped between the ends of the bones and prevents them moving freely on each other. Until this is released from its position the deformity must remain unrelieved. If left to itself the finger generally re- covers a good deal of its power, but the appearance is very unsightly. The Muscles. The muscles round joints rarely escape when the sprain is severe, though the injury may at first be masked by other symptoms. Sometimes it is very serious, but this depends probably on their condition at the moment of the ac- cident. If they are firmly contracted and ready to resist, the joint does not suffer unless they are overcome, and then the injury is generally too great to be called a sprain. Most often they are taken by surprise, and are hurt more by their own sudden and spasmodic effort at recovery than by anything else. The weakest part of a muscle varies a good deal according to its shape. When they are short and broad, with wide at- tachments to the bones and firmly bound down by sheets of fibrous tissue, there does not seem to be any definite rule. Probably the part that gives way first is determined mainly by individual peculiarities of structure; but when they are of considerable length, and attached to distant bones by rounded tendons, the weakest part is the line of junction between the muscular fibres and the connective tissue. It is at this point that they tear, causing a great extravasation of blood, and giving rise to a swelling which at first is soft and fluctuating, but which soon becomes hard and solid, and may persist in that condition for an almost indefinite period. Sprains ; their Consequences and Treatment. 49 This often happens when the fibres are torn across, while the dense unyielding- sheath that surrounds them remains in- tact. The extravasated blood is tightly bound down, and forms a hard resisting- nodule, the nature of which can only be ascertained by the rapidity with which it occurs and the way in which it is confined to the limits of the muscle. I have recently had under my care a patient with a nodule of this kind in one of the muscles of the neck just where the tendinous and muscular fibres meet. It made its first appearance quite suddenly during- a violent effort, with all the characteristic signs of muscular rupture, more than a year before, but in spite of energetic treatment by massage and other methods it was nearly three months before it finally disappeared. When a muscle gives way completely, it is usually at the same spot. A curious instance of this is not uncommon among butchers. They occasionly lose the last joint of their thumb by catching it in a hook and tearing it off. The skin and the ligaments give way at the seat of injury, but the tendons of the muscles retain their connection with the bones. The long- flexor is pulled out of its sheath for five or six inches, one end remaining attached to the bone, the other bringing- away with it torn shreds of the muscular fibres that have given way above the wrist. Rider's Sprain. Sometimes the muscles are torn and strained without the joints being hurt at all. Those, for ex- ample, that lie on the inner side of the thigh occasionally give way under the semi-voluntary grip by which a rider secures his seat when his horse swerves or bolts round. There is a sudden sharp contraction, a sensation of something- giving way, and a feeling- that the hold on the saddle is g-one. A dull ach- ing- pain sets in at once, and grows worse and worse with every attempt to proceed; the part begins to swell as the blood pours out from the torn vessels; a peculiar warm trickling sensation is felt down the inner side of the leg-, and, as a rule, the rider is compelled to dismount. When standing, the symp- toms are not quite so severe, but the least attempt to bring that group of muscles into play again, or to remount, makes them tenfold worse. The kind of injury is well known, and is usually recognized at once. It is due to the rupture of the tendon that stands out under the skin on the inner side of the thigh ; sometimes it 50 Sprains ; their Consequences and Treatment. gives way near the bone, so that the gap can be felt, but more often the muscular fibres are torn away from it without leav- ing 1 any distinct interval. The extravasation is often very ex- tensive, and it may be weeks before the last traces of the staining finally disappear. Every endeavor must be made to keep it as much as possible within bounds. A stirrup leather may be tied tightly round the part as a temporary measure; but a much more effectual method is to buckle a long strap of webbing round the thigh, outside the breeches. It must be well padded, on the inner side, over the point where the muscle is torn, and coming up in front and behind, should cross over the hip and be carried round the waist. Where the laceration is complete, some such appliance may be permanently required. Eider's Bone. A long slender spine of bone which is oc- casionally met with in connection with these tendons probably has its origin in the same kind of injury. It is known as rider's bone, from its being found chiefly in those who have spent a large proportion of their lives in the saddle. Some- times it causes a good deal of inconvenience by the way in which it interferes with the flexibility of the part; but more often its existence is hardly known, as it lies buried in the sub- stance of the tendon itself. If the history is inquired into, it is always said to have developed after one single severe strain; but comparing it with similar formations in other tendons, it seems more probable that it is due to the constant bruising to which the muscles are subjected. Probably it is formed from the organization of lymph thrown out from time to time. Rider's Bursa. Other troubles also are produced in this way. A soft fluctuating swelling sometimes makes its ap- pearance underneath the tendon, high up in the groin. So long as the muscle is in action it is tense and firm, as soon as it is relaxed it becomes soft and flaccid ; but it cannot be dis- persed, or even reduced in size, by pressure. In one case under my care, considerable improvement was effected by rest and blistering, but I am afraid it was not permanent. The patient was a man who had been accustomed to a great deal of rough riding, and it seemed to cause him considerable annoyance. The thing of which he complained most was a sensation of weakness, similar, apparently, to that which is so often ex- perienced in the hand when there is a ganglion on the back of the wrist; but it was doubtful if there was any actual loss of COLL" Sprains; their Consequences and Treatment. 51 power. The swelling- had made its appearance slowly, and was still increasing 1 when he came to see me, so that it evidently was not due to any extravasation. Most probably it resulted from the effusion poured out after repeated strains; and, as he could not give up his occupation, it is certain to increase, until it ends either in inflammation and suppuration or else in the for- mation of a bursa. Lawn Tennis Leg. Lawn tennis leg- is another instance. This was a well-known form of accident long 1 before lawn tennis was ever played; but it has become so much more common, as the game has grown popular, that perhaps the name is not inappropriate. It is most frequently met with in men, es- pecially in those who, as youth passes by, are beginning- to in- crease in weight, and whose muscles are somewhat out of training; but not improbably there are other causes too. It is decidedly rare, for instance, among the laboring classes; I am not aware myself of having seen any example among the out-patients at hospitals ; and, whether it is worth anything or not, it is certain that in a very large proportion of the cases some evidence of gout may be found, not necessarily of any very acute attack, but merely of those indefinite forerunners which are often quite as distinctive. Generally speaking, it occurs during some sudden and violent effort, a sudden spring forward to take a ball, for example; but the merest slip is enough. Indeed, in some cases it is so difficult to obtain a definite history of such an accident that I am rather sceptical as to its really being required. I have known at least one in which it occurred while the patient was walking along a level road, on which there was not even a projecting stone. The symptoms are exceedingly characteristic. All of a sudden there is a sharp stab of pain in the calf of the leg; the patient stops instantaneously, lifts his foot from the ground, and nearly always looks round to see if some one has not struck him a violent blow with a stick or a stone. Rest his weight on the leg he cannot ; the pain, it is true, does not continue with the same intensity, but the recollection is such that noth- ing will induce him to try. When the part is examined, there is generally nothing to be seen; but there is an exceedingly ten- der spot in the substance of the calf, and sometimes a slight depression can be felt. Later on, marks of bruising make their appearance, yellow at first, but gradually becoming darker as MJOO .MCM-14 Sprains ; their Consequences and Treatment. the coloring- matter approaches the surface, and, generally speaking, most plain toward the lower part of the leg, even when the painful spot is nearer to the knee. This, however, is liable to be modified considerably if the part is well band- aged. In one or two cases I have noted a slight degree of puffy swelling behind the ankle, and it is said that occasionally the foot is deflected somewhat from the straight line ; but this I have never seen myself, and I should feel inclined to assign it, when it is present, to secondary changes taking place in the smaller joints of the foot, consequent on the very unequal and unfair degree of strain thrown on them. The usually received explanation of this very striking- acci- dent is that it is the result of the rupture of an exceedingly small muscle, known as the plantaris, situated in the substance of the calf of the leg-. The muscle itself is in many respects most peculiar; it is very deeply placed, lying under the largest muscle of the calf, is itself exceedingly short and weak, being- rarely three inches long, and is provided with a prodigiously long tendon, which either joins the tendo Achillis at the back of the heel, or else is attached to the bone in close proximity to it. Whether rupture of such a structure can take place or not is almost impossible to prove ; the fact is commonly asserted, and it is usually admitted as an explanation of the symptoms, but I am not aware of any instance in which it has been actu- ally shown. It is quite certain that the same effect may be produced by other causes. This explanation, for example, does not answer when the same accident occurs twice in the same leg- at different places. A striking- instance of this recently came under my notice, the interval between the two occurrences being only a few weeks. On the first occasion the middle of the calf of the leg- was the part involved; on the second it was at least four inches lower down, and nearer to the ankle. Nor was this to be explained as the rupture of muscular adhesions that had developed dur- ing- the period of convalescence ; for not only had there been nothing to occasion them in this locality, but recovery was / practically perfect, so that the patient could walk without in- { convenience, and without any apparent limping. The second accident was precisely of the same nature as the first ; there was the same sharp stab of pain, with tenderness, and a slight amount of swelling, and the same feeling that it was impossible Sprains ; their Consequences and Treatment. 53 to place the foot upon the ground ; but clearly it could not be due to the tendon. This, if it had united at all, could not have been sufficiently firm to withstand a strain that compelled it to give way at another part. The scar could not have been so strong as the original structure. W. Hood (Lancet, 1884) considers that it is the result of the rupture of some portion of the muscular or tendinous structure of the calf, without specifying- it more particularly ; and no doubt this is correct in many instances, especially when a depression can be felt by the finger where the fibres have given way. Rupture of the plantaris, which is comparatively a deeply-seated muscle, could never cause this. I would vent- ure to suggest, however, that, in those cases at least in which the amount of blood extravasated is considerable, the cause is connected with the condition of some of the deep intermuscu- lar veins. In many instances they are unusually large; they become varicose, nearly to as great an extent as the superficial ones, and there is no doubt that sometimes they give way, or become blocked by the development of coagula in their in- terior. This naturally causes very severe pain, owing to the way in which the nerve-fibres are stretched or compressed ; and unless absorption is completed very soon, is sure to leave be- hind a considerable degree of stiffness. The degree of pain that is caused by the rupture of a small vein, especially when the extravasated blood is bound down by surrounding text- ures, is something- surprising- so long as it lasts. The method of treatment to be adopted in these cases is admirably described by the same writer. He recommends that as soon as possible after the accident the patient should be placed in the recumbent position, with the injured leg- raised above the level of his head, and should be kept in this position for five minutes. This is very important for two reasons. In the first place, the leg- is emptied at once of all superfluous blood, so that the swelling soon goes down. When a limb is raised in this fashion the artery contracts ; much less blood flows to it, and the veins are so rapidly emptied that if a su- perficial one has given way this alone is sufficient to stop the bleeding-. The calf, which is enlarged and hard, returns to its normal size, and the patient at once obtains relief from the distressing feeling of tension. But besides this, if the elevation of the limb is neglected, the plaster next to be described is 54 Sprains ; their Consequences and Treatment. loosened by the subsidence of the swelling-, and requires to be replaced in a few hours. He then advises that while the leg- is still raised strips of adhesive plaster, each an inch and a half in width and of length adapted to the size of the limb, should be applied from two inches above the ankle joint to above the thickest part of the calf, somewhat as strapping- is applied in the treatment of chronic ulcers of the leg-. As soon as it is applied the patient should be directed to walk about the room, and to place the heel firmly, or at least fully, on the ground at each step. For the first dozen steps he will prob- ably hesitate, and will retain more or less of the limp with which he entered ; but after a short time, finding- that his pain is diminished or possibly removed, he will g-ain confidence, and will walk with a pride in his own performance which is very interesting- to witness. This description is exceedingly accu- rate : " Until this point is reached he should not be suffered to depart; for, if he does not walk properly before he leaves the surg-eon, he will hesitate still more when alone, and will be likely to return to the ungainly progression which he ex- hibited at the commencement of the interview. Success in walking-, in the first instance, will depend largely upon the temperament of the injured person. A resolute man, who be- lieves in his doctor, will walk at once, while a more timid patient will require coaxing- and urging-. The chief trouble will be with the sceptical man, who has his own ' views' about the injury, and who will express them in such questions as, ' Well, but do you not think there is a risk of inflaming my leg ? ' ' Shall I not make the internal wound larger ? ' and so forth. With reasonable care neither to jerk the leg nor to twist the ankle on uneven ground, the patient, as soon as the plaster is applied, may walk about as usual. J$y the third day the plaster will be some\vhat loose, and the patient will say that he is not quite so comfortable as before, and is less inclined to trust his leg. The strapping should be reapplied, and he will at once feel more secure and better able to walk. Four days may elapse before the next strapping, which may be left untouched for a week, but the application should be continued at intervals until the patient is quite convinced of his ability to do without it. On the first occasion very little pressure is desirable, and mere laying on of the plaster will be sufficient. Subsequent strappings should be tighter, but never Sprains ; their Consequences and Treatment. 55 so tight as to produce a sense of unpleasant constriction, a rule which must be especially borne in mind in applying the first and last piece. The amount of walking should be increased daily, and after the third day the patient should go up and down stairs freely in the usual manner. Until then his ascents and descents may be infantile." I would only add that in those cases in which I believe the real cause to have been the rupture of some deep-seated vari- cose vein, I have found the above-mentioned method of treat- ment as successful as when the muscular fibres were plainly torn. In other parts of the body partial rupture is equally common. Sometimes only the sheath of fibrous tissue that surrounds the muscles gives way; the soft tissue is squeezed out through the rent, and so tightly constricted at the opening that it becomes forced into the shape of a mushroom. I have seen this in the extensor muscle on the front of the thigh. It was attributed at the time to the fact that the patient received a violent blow on the spot from a blunt piece of iron at the moment of vigorous contraction. The symptoms, however, were not well marked, and as recovery was complete without further inconvenience than a small depression in the substance of the muscle, nothing further was seen of it. Many other tendons occasionally give way during great exertion. Even the stoutest, such as the tendo Achillis, may be torn across, though it is more common for the bone or the muscle to yield instead. I have in my possession a shoulder joint in which the long tendon of the biceps has been ruptured about an inch and a half from its attachment to the bone, so that the end projects into the cavity of the joint. The other part has formed for itself a secondary attachment on the floor of the groove in which it normally lies. Similar changes have been described from time to time in connection with many others. Dislocation of Tendons and Muscles. When the injury falls short of actual rupture it may still be very severe, and lead to a great deal of after trouble. Tendons, for example, where they cross a joint or run over a projecting process of bone, lie in grooves, which, are lined with a delicate sheath similar to that in joints, and this rarely escapes. In slight cases it is merely bruised where the tendon presses against it, but it may be filled with extra va sated blood, or be torn open 56 Sprains ; their Consequences and Treatment. down the whole of its length, while the tendon escapes and lies displaced among- the adjacent tissues. In the Back. Both muscles and tendons may be dislocated in this way. Callender and others have shown how this hap- pens where long and slender slips lie embedded among shorter and stronger ones, as in the back and some parts of the limbs. The muscles are closely packed together, surrounded, and at the same time separated from each other, by fibrous tissue, which is dense and firm toward their ends, soft and yielding at their centre. In all ordinary movements, carried out in an orderly fashion, with a definite object in view, the action spreads, as it were, from one muscle to the next. Very few are carried out by the contraction of a single one. Nearly all involve not only those immediately necessary, but those also by their side, which are more or less parallel in their course. The shape and consistence alter together, so that their mutual relations remain unchanged. When the contrac- tion is sudden and spasmodic, it sometimes happens that one of these slips from its bed between the rest, tearing its fibrous sheath, and becomes displaced or dislocated. Probably this is due to the irregular and disorderly fashion of the contrac- tion. There is a sudden pain, quite local, but made worse by any movement that would call that muscle into play, some- times so severe that such movements cannot be executed at all. The surface of the skin is slightly raised if it is superficial, and nearly always there is considerable local tenderness. These symptoms are, it is true, very nearty the same as those of partial rupture, which is a great deal more common ; but there is no question that dislocation does sometimes hap- pen, as complete and almost instantaneous recovery takes place as soon as it is reduced. In some instances the patients have actually felt the muscle slip back into its place again; and in a few it has been known to slip in and out again and again, owing to incautious movement at a too early period. The Sartorius. Large muscles, too, are occasionally dis- placed. A remarkable case has been recorded in which the sartorius was detached from its position on the inner side of the knee by an accident of this kind. Just before its attach- ment to the bones of the leg, this muscle gives off from its border a tough fibrous expansion to the capsule of the joint. This was torn across, and the muscle itself displaced. The Sprains ; their Consequences and Treatment. 57 accident befell a man who was squatting on the floor of a wagon in the position assumed by tailors. A companion trip- ped over him and fell across his knees ; something was felt to give way near the ham, and on examination the above mischief was made out. In another instance under my own care, after a somewhat similar accident, there was much tenderness, and a soft ill-defined swelling over the inner side of the knee for a considerable time; and all the movements that require the assistance of this muscle were very painful, as if some of its fibres had been torn across. Peroncei Tendons. The tendons of the peronsei muscles, again, are not unfrequently displaced from their position be- hind the outer ankle. The sheath that confines them in their groove is torn down its whole length, and they slip forward on to the bone. In the two examples that have come under my immediate notice, neither of the patients was sufficiently trained in accurate observation to give a reasonable account of the way in which the accident occurred. It is not hard, however, to conjecture the direction in which the foot must have been twisted for such displacement to be produced. One of them had sprained the same joint already several times be- fore, and although the tendon had never been completely dis- placed, it is by no means improbable that the constant repeti- tion of the injury had caused the sheath to stretch until it became too weak to resist. It is possible, too, that the groove in the bone had become partly filled up by the lymph thrown out. In neither was there the least difficulty in reduction ; but while this was successful and permanent in the case of the one, in the other the least movement caused them to slip over the bony margin again, confirming my suspicion that the mis- chief was not due to one accident only. Bandaging, strap- ping with pads in all positions, fixed apparatus of many kinds, complete rest, with the foot kept at a right angle for weeks together, all were of no service. Gradually the inconvenience became so much less that the patient would not submit to any further treatment. At first, each time they slipped forward there was the peculiar sickening pain common to all over- stretched fibrous textures; but soon this, too, ceased to be felt, and the patient having had no arch to his foot for some long time before, the comparative loss of these muscles was not so serious to him as it otherwise would have been. 58 Sprains ; their Consequences and Treatment. On the Hand, etc. Other tendons do not so often suffer in this way. Paget has described displacement of some of the extensor ones on the back of the wrist; but though a slight degree of slipping and yielding at this point is very common, complete dislocation rarely happens, probably because the direction in which they run deviates so little from the straight line. In bad cases of knock-knee, the knee-cap lying in the tendon of the great extensor often slips to the outer side of the joint when the limb is straightened; and the same thing sometimes occurs during flexion, from defective development of the lower limb, associated with a peculiar kind of deformity; but neither of these can be fairly regarded as dislocation of a tendon due to injury Biceps. Whether the long tendon of the biceps can be displaced from the groove in which it lies seems still not quite certain. I have seen one case in which this peculiar injury was diagnosed, and although verification was not possible, I think there can be no doubt not only that the tendon did actually slip out of its bed, but that by twisting the arm round, which the patient could do by means of his other hand, it could be made to slip in and out again at pleasure. No snap could be heard, it is true, nor was there any distinct difference along the front of the arm when the two sides were compared to- gether; but the inability to raise the arm from the side at one moment, and the comparatively free range of action after reduction had been effected, left little doubt that it was a genuine example. Passive motion was fairly good, as it was in the case described by Hamilton, only somewhat painful. There was no undue prominence on the front of the shoulder, possibly because of the recent date of the accident. The case, it is admitted, is incomplete, and as the patient was under my observation only a short time, I cannot give any account of the subsequent progress. It does not agree in all respects with those recorded; but as Hamilton has shown by actual dissection the possibility of such an accident, and as I cannot understand what other displacement in the region of the shoulder could have produced so peculiar a train of symptoms, sometimes well marked and definite, and then all of a sudden disappearing for a time, I think it must be allowed. In old cases of rheumatic gout it is not at all uncommon to find the groove filled up, and the tendon flattened out over some ad- Sprains ; their Consequences and Treatment. 59 jacent part of the head of the bone, but there was no evidence of disease in the present instance. Ruptured Veins. The presence of varicose veins is often a serious matter when the ankle joint is sprained, particularly in the case of a person who is advanced in life ; and in this re- spect minute vessels^ which give rise merely to a mottled bluish appearance of the skin, are, perhaps, more to be appre- hended than when one or two of the larger trunks only are involved. The actual amount of blood lost may not be so great, but the tissues do not seem so well nourished, and ab- sorption is much more slow. It must not be forgotten either that the deep intermuscular veins are often as much dilated as the more superficial ones, and that when they give way a very large quantity of blood may be effused into the deeper strata of a limb before making its appearance on the surface. The inconvenience that results from this is very serious, and convalescence is much protracted ; for until the whole of the blood thus effused is absorbed the muscles do not recover their freedom of action, or the subcutaneous tissues their normal supple feel. Rigidity and oedema, worse when any exertion is made, may persist for months solely owing to this. Injury to Bones. This even does not exhaust the list of structures that may be injured. The bones themselves are frequently bruised, especially when, either from delicacj 7 of constitution or other causes, such as disease, their substance is soft and vascular with an undue amount of fat in their com- position. It is true these injuries are not often demonstrated, though I have sometimes found dark stains, due to hemor- rhage, deep in their substance; but inflammation is sufficiently common to make it unreasonable to doubt that they too meet with their share of damage. Diseases of the spine, hip, and other joints in children may be due, in great measure, to some constitutional taint, though it is open to question whether the influence of this is not overrated ; but it is quite c.ertain that the immediate starting-point in nine cases out of ten is some chance sprain, often so slight as scarcely to have been noticed at the time. CHAPTER V. INFLAMMATION AND THE PROCESS OF REPAIR. THE changes that take place in the tissues after the imme- diate effects of the injury have disappeared cannot be allowed to pass without some degree of notice. It is true that there is little that is special or peculiar about them ; they are in nearly all respects identical with those that follow fractures or other injuries; but, for some reason or other, it is the popu- lar impression, one that is shared, too, by not a few medical men, that these accidents are almost invariably followed by acute inflammation. Imperfect recovery is, I admit, exceed- ingly common ; it is the frequency of it which makes sprains so serious; but, rightly or wrongly, inflammation is nearly always regarded as the cause. If it is the case, it is only reasonable that it should be allowed a certain amount of in- fluence on the kind of treatment adopted. At first sight, I am bound to confess, much apparently may be said in favor of this opinion. There is nearly always pres- ent in these cases a cavity of some kind or other, whether it is a joint, sac, bursa, or tendon sheath; and this is certain to be distended under considerable pressure by blood or lymph, which, unless active measures are taken, is very slowly re- moved by absorption. The quantity that may collect in a few minutes is enormous ; I have on many occasions seen the wrist double the circumference of its fellow within half an hour of an accident. Naturally the degree of tension is very consider- able; the sensory nerves are stretched or compressed; the part begins to throb ; the skin becomes hot and red ; and, to all appearance, there is the commencement of an attack of acute inflammation. Now, there is no question that if this is allowed to continue unchecked it is very likely to be followed by this result ; but if due and proper precautions are taken against it there need Sprains ; their Consequences and Treatment. 61 not be the least fear. When inflammation breaks out, it is either the consequence of neglect, maltreatment, or some pecul- iarity of constitution, such as gout or struma, so marked that the least accident is sufficient to precipitate an attack. The changes that take place in the tissues after sprains are merely those necessary for the repair of the damage ; it is only when they are encouraged beyond measure by other causes that inflammation is likely to break out. Hypercemia and Softening. As soon as the bleeding- is checked the vessels all through the injured area dilate, and their walls become relaxed and softened. The volume of blood circulating 1 through the part is immensely increased ; a much larger amount of liquid plasma pours out through the walls into the tissues round, mixing with the blood that has already been extra vasated. All the interstices are filled with it, and become distended more and more, until the joint swells up and the skin becomes tense and shining from the way in which it is stretched. The ditferent tissues are affected, of course, in different degrees ; the capsule itself, owing to its delicate con- struction, very soon becomes thickened and softened; the loose tissue round it is affected even more quickly; the ligaments, from the way in which their fibres lie close set against each other, resist much longer; but they, too, at length, if the process continues unchecked, undergo a similar change, so that the softening and distention become general. Effusion and Distention. The fluid pours at once into any natural spaces, such as tendon sheaths or bursse, that may be present. These and the synovial sacs of joints are the first to become distended, so that for some time the shape of the swelling follows distantly the natural contour of the part. Later, \vhen the connective tissue round becomes softened and the swelling more general, this is lost, and the outline is rounded and uniform. At this stage the skin may be whiter than natural, though the temperature when the hand is laid upon it is higher than that of the corresponding point of the opposite limb ; the superficial parts are so tensely stretched that the blood-vessels are emptied by the pressure, but the sensation of warmth is still transmitted from below. Very little of this, of course, is to be seen post-mortem. No hyperaemia can be found then, no matter how great it was during life. It disappears with the vitality of the part, and 62 Sprains ; their Consequences and Treatment. its extent and degree can only be conjectured from the few signs it leaves behind. Minute extravasations may be found here and there, especially among the softer parts; and the fluid in the cavities may be stained with blood in different de- grees, or, it may be, turbid from shreds, and flakes of fibrin or mucus floating- in it; but apart from the actual lacerations, nothing further can be seen in the earliest stages. At a later period the changes are better marked. The smooth glistening polish on the inner lining of the joint is gone; in its place there is a dull and lustreless surface, stained and discolored by the blood, and coated over with a deposit similar to that which makes the fluid in the interior turbid. In recent cases this may be washed off; after a time it appears to be incorporated with the wall itself. The two cannot be separated, and if a small portion is removed and examined under water, a number of little gelatinous processes float up from the surface, so that it looks something like a piece of coarse velvet. This is particularly marked over the softer parts of the capsule, where the sy no vial membrane is thrown into folds, or where masses of delicate and vascular connective tissue project into the interior for the pupose of filling up the irregularities between the bones. On the other hand, where the ligaments directly bound the cavity, merely covered by a layer of cells, with no soft intervening stratum, hardly any such change is to be seen. So it is with the cartilage that covers the bones; it scarcely shows a trace; even the blood stains cannot penetrate beneath the surface. Organization. The softer and looser the tissue the greater the effect. Round the edge of the joints, sp to speak, outside the line of pressure, where the fibrous capsule is attached to the bones, and where the synovia! membrane lies folded on itself, and, as age advances, becomes covered over with fringes and villous processes, the bruising and softening are most conspicuous. It is not the surface, or the lining membrane only, that shows the change ; the whole thickness of the cap- sule is affected, and where it is thin and delicate, or where, owing to the shape of the bones, there are hollow spaces round on which pressure never falls, the tissues outside suffer too. In more than one example I have seen this extend long dis- tances by the side of the bones; and it is, I believe, in great measure owing to this that many sprains, apparently trivial Sprains; their Consequences and Treatment. 63 at the outset, are followed by such impairment of mobility. Unless measures are taken to prevent it, the whole of the fibrous structures at this part, the folds of the synovia! mem- brane, the capsule, and the loose tissue outside it, appear to be lost in a soft, gelatinous mass of lymph, in which a few fibres here and there can still be found. If the joint is allowed to remain unmoved this fills up the entire hollow between the bones. Then, after the effect of the injury has passed off, when the hypersemic stage is becoming- less marked and repair is carried on more actively, it becomes organized, and converted into dense, unyielding, fibrous tissue, which ties the bones to- gether, and to a great extent cripples the joint. It is not the fault of the synovia! membrane alone, or the capsule, or the soft and loose connective tissue on the outside ; they all play their part, though the share each of them takes may show a certain degree of difference in different cases. In Joints. In the shoulder, for example, stiffness of this description is of common occurrence, and may lead to serious inconvenience. At the lower and inner part of the joint the capsule is very thin, and has round it a large amount of loose fibrous tissue, so soft and delicate that it is thrown into folds when the arm is hanging by the side. No pressure falls on it so long as the limb is in the natural position ; as it is raised from the side the folds are gradually straightened out, until they are put upon the stretch by the pressure of the head of the bone. Now, when the joint is sprained or hurt, this part of the capsule, owing to its softness and vascularity,is exceed- ingly likely to be injured; and unless active measures are taken to prevent it, the whole of it is very easily converted, first into a mass of soft, vascular lymph, and then into dense and un- yielding fibrous tissue. There is nothing to prevent it. There is no pressure to close the vessels and limit the amount of lymph thrown out, or to help on the process of absorption; the folds are never opened out or separated from each other; if the joint is in the least degree painful it is kept at perfect rest, owing to the presence of others close by ready to under- take its work, and all the time without the patient being aware of it. When he is directed to raise his arm sideways from the body, he imagines he is using his shoulder joint, while, as a matter of fact, the whole of the action is being carried out by others ; and this goes on until, by degrees, organization com- 64 Sprains ; their Consequences and Treatment. mences, and the part quietly becomes stiff and rig-id. The sur- faces of the folds become adherent to each other, and incor- porated with the tissue round; and instead of a soft and flexi- ble capsule, there is a mass of shortened, rigid, and unyielding- fibrous tissue, matting 1 everything together, and not only by its strength preventing proper movement of the bones, but, by the pain it causes when any attempt is made, preventing any vigor being thrown into it. Between Muscles. Similar changes take place in the planes of the soft, cellular tissues that surround muscles, lying between them and other structures. The blood, escaping into these from the torn vessels, makes its way along the line of least resistance until it reaches some part where there is no pressure or movement. Here it remains, passive and un- changed, for a considerable period ; but at length it slowly be- comes organized, and by gluing together the different strata, gives rise to the stiffness and loss of power that are so com- mon after severe muscular strains. In Bursce. The effect produced by large bursae has been already mentioned in speaking of joints. Many of them are merely open spaces in the connective tissue, lined by a single layer of cells, and, in ordinary circumstances, contain merely sufficient fluid to enable one surface to glide freely and smoothly on another. In reality they are formed, as required, out of the intercellular and interfibrillar spaces that exist everywhere in connective tissue. After sprains they act as receptacles for blood and lymph, and often become immensely distended. If the fluid is quickly absorbed again there is no ill result ; the walls contract, and -the cavity resumes its former size and shape ; but if there is any delay when at length absorption does take place, the softened and relaxed walls are thrown into folds, so that the sides grow together and become incor- porated with each other. Instead of there being a thin-walled sac, assisting every movement by diminishing friction, there is a rigid mass of tissue, stiffened, irregularly thickened, and adhering to everything round it, the seat of constant pain and tenderness. "When this change is established, restoration is much delayed. The progress at first is often rapid, the later stages are sure to lag behind ; and the longer the thickening 1 and infiltration of the tissues have lasted, the greater difficulty there is in getting rid of them. Sprains ; their Conseqiiences and Treatment. 65 Inflammation. These changes are not due to inflamma- tion. Pilcher, in describing the consequences of sprains affect- ing- the wrist joint, has shown the difference between them with admirable clearness. It is perfectly true that the parts are swollen from the extravasation of blood, and the effusion of lymph ; that the skin is sometimes reddened, and the tem- perature raised, owing to the increased amount of blood circu- lating in the vessels of the injured area; and that there is tenderness and pain, partly because the nerves are torn across, partly because the sensitiveness of the skin is heightened; but this, though it may end in it, does not make up inflammation. The increase in the flow of blood is the natural outcome of the injury. A certain amount of repair is always being carried on, in correspondence with the ordinary wear and tear of everyday life. At times, from accidents or other causes, this work undergoes an immense increase ; then, in accordance with the physiological laws which control all parts of the body, a much larger amount of blood flows through the part, and a greater quantity of reparative lymph is poured into it. So long as the skin remains unbroken, it is altogether un- usual for injured parts to become inflamed. Except under such circumstances as blood-poisoning (when any injury leads to abscess), or where from some accidental cause, such as the rupture of a large artery, a high degree of tension is set up in the tissues, inflammation following a subcutaneous injury is the exception, not the rule. Fractured bones, when the skin is unbroken, hardly ever excite inflammation; contusions and bruises may more often, because it is more common in them to meet with tension from fluid that is allowed to accumulate ; sprains form no exception. Inflammation may set in from maltreatment or neglect ; from peculiar conditions of the blood (such as gout or rheumatism) in which inflammation of joints sometimes occurs without any injury at all; or if a large amount of blood is allowed to accumulate, just as it sometimes does after a bruise; but under ordinary conditions it is not a necessary consequence, and may nearly always be prevented. This is of material importance in the question of treatment. As regards the time at which this should be commenced, most people are agreed ; and the methods adopted for the earliest stage have (most of them) something to be said on their be- half; but when the second stage is reached, as Pilcher, Hood, 66 Sprains ; their Consequences and Treatment. and many others have pointed out, the mistaken notion of in- flammation being- a necessary consequence, has given rise to a plan which is not only directly opposed to all that is rational, but which, as mig-ht be expected of anything- of which such a statement can be made, is to be reg-arded as the immediate cause of many of the troubles of later times. Small blood- vessels are always torn across when such accidents happen; sometimes the number is considerable; a certain amount of extravasation necessarily follows; this must be absorbed, and the injured tissues repaired or replaced, before the part can be said to have recovered, but it is always effected by perfectly natural means. The amount of blood that circulates through the part, and the quantity of lymph that is poured into the tissues, are increased in proportion to the work that has to be done. The softening of the intercellular substance is to facili- tate this. It is only when the process passes beyond what is needed for the purpose, and becomes continuous and progres- sive, that it deserves the name of inflammation. It does not do, however, on this account to run to the other extreme, and declare that inflammation never occurs. If a larg-e amount of blood escapes from the vessels into the tissues, or if from using- the joint too freely or too soon after it has been hurt, the hyperasmia is not allowed to subside, it is almost certain to do so. Anything- that causes a high degree of ten- sion is sufficient to induce it; the part begins to throb; the temperature rises; the swelling- increases more and more until it may declare itself at any moment. It is more likely to break out in certain constitutions, and in certain joints; but if any synovial sac, or bursal space, is allowed to become dis- tended, it follows as naturally as it does elsewhere. Only, so long- as the amount of effusion is confined within due limits, so that the tissues can deal with it with a little assistance, without being- overtaxed, inflammation is the exception, always provided there is no constitutional predisposition to bring it on. Absorption. These are the chang-es that take place in one direction. Side by side with them, commencing- more slowly, it is true, but steadily progressing- until it gains upon, and finally overtakes them, is the process of absorption. The sooner it begins, and the greater the activity with which it is carried on, the better the prospect of speedy recovery. When Sprains ; their Consequences and Treatment. 67 it is incomplete, the consequences are always serious. As already mentioned, inflammation may set in and end in grave disease; the synovial cavity of the joint may continue dis- tended with fluid until the capsule loses its elasticity and can- not contract again ; the ligaments may be stretched and soft- ened; there may be hard, unyielding masses of old blood clot lying among the tissues, and causing pain by pressing upon the nerves; or bands of lymph, converted into fibrous tissue, may pass from one bone to the other across the joint, making it stiff and rigid, and preventing free movement. Sometimes (after a sprained ankle, for instance) the soft tissues behind the bony prominences remain swollen and puffy for years, get- ting better from time to time, and then, again, especially of an evening or after any exertion, swelling up more than ever. At others, the nutrition of the part does not recover, and it remains cold and stiff, with a look of utter helplessness about it. Whenever, in short, recovery after a sprain is incomplete, and no actual displacement or other gross lesion can be found to account for it, the real fault is that absorption has never been thoroughly carried out, and that the circulation is not restored. The perfect recovery after these injuries is, however, of so much importance, and is so intimately bound up with the question of treatment, that it must be dealt with by itself. The track of the extravasated blood, as it is absorbed, is easily made out. The red blood corpuscles break down, and are destroyed ; their coloring matter dissolves in the fluid, and soaks into the tissues along the easiest routes, marking its path by the staining of the skin. The distance this spreads, and the length of time it lasts, maj^ give some idea of the slowness with which absorption is carried on, even when the area is extensive. It is no uncommon thing for the bruising of a sprained ankle to reach the knee; and it may be many weeks before the last trace has vanished. Even then it dis- appears from the connective tissue interspaces outside the joint more rapidly than it does from the synovial sac within, or the bursae and tendon sheaths round. In the one case it is widely diffused among the fibres, lying actually in the little interstitial spaces, out of which the absorbent vessels spring; in the other it occupies a cavity, only part of the wall of which possesses any absorbing power, and that not in a very high degree. Sometimes, owing to this, a few days after a sprain, 68 Sprains ; their Consequences and Treatment. the joint appears larger in proportion to the parts round than it did shortly after the injury. Gradually the semi-fluid material between the cells and fibres diminishes in amount, and becomes firmer in consistence ; the surplus lymph, not needed for the repair of the tissues, is carried off, taking with it the remaining debris of the red blood corpuscles; and the nutritive plasma circulates again in normal amount, and at its normal rate, through the tissues. Effects of Pressure. It is worth noting how immensely these changes are assisted by the judicious use of compression. The extra vasated blood betrays its presence everywhere by the stains upon the skin. In nearly every case it follows defi- nite directions, being guided along certain strata either by the arrangement of the stronger sheets of fibrous tissue which surround and separate groups of muscles, or else by pressure applied from the outside. Where the bones lie immediately under the surface, so that the skin and subcutaneous tissues are firmly compressed when a bandage is applied, the color remains white and unstained. In the hollows between the bones, or behind eminences, which protect the soft parts, the tissues are swollen and puffed out, and may be jet black for a time. So it is with the effusion of lymph at a later period ; only owing to there being here no alteration of color, the signs. are not so conspicuous. The swelling always disappears first from those parts on which the pressure falls ; it persists long- est in just those places where it effects most mischief, in the little irregular hollows that lie between the bones, especially,, as has been mentioned already, in the case of the shoulder, on the side where the tissues are softest and most yielding. As the tissues shrink to their former size, the lining mem- brane of the joint cavity slowly resumes its natural appear- ance. Granulations cease to form on the inner surface; the latest formed cells, instead of dropping off into the fluid, be- come firmer and flatter, and are held together better by the cementing substance, so that they reproduce the glistening surface of the synovial lining. The fluid becomes more clear again, and its normal color and consistence return, though the quantity may continue excessive for a very considerable time. Permanent Changes. The fringes, and the tissues at their base, retain their altered character the longest. Often, indeed, they never quite regain their farmer size or texture. They Sprains ; their Consequences and Treatment. 69 become firm and hard, and more opaque from the organiza- tion of lymph in their substance. Sometimes the larger ones become vascular, a loop of blood-vessels growing 1 down into them from the base ; and then they are practically permanent. If a joint has been sprained more than once, their presence can nearly always be detected in certain favorite localities, as, for example, on either side of the knee-cap. Owing to the synovial membrane being so superficial here they can be felt quite dis- tinctly, even when they are still small, rolling between the finger and the bone. So long as they remain small they scarcely give rise to a sensation of inconvenience, but when they reach any size they act to all intents and purposes as so many fixed foreign bodies. Owing to their position, well out of the way of the bones, they do not often get caught between them, or they would prove a grave source of danger; but even though they escape this, they keep up a continuous if slight amount of irritation; the hyperaemia and effusion never quite disappear; the capsule and the ligaments become involved more and more, and the strength and security of the joint at length are seriously impaired. Length of Time. Where ligaments have been torn,whether they are completely separated in two, or, what is more usual, have merely sustained a number of small lacerations in their substance, it is, of course, a matter of some considerable time before perfect repair can be effected. So it is when muscles or tendons are torn, or if the sheath in which they lie is widely rent ; and above all, if, before the parts are firmly united an- other undue strain falls on them. When this occurs, not only is the whole of the original mischief reproduced, but the de- gree is, generally speaking, more severe; for, owing to the vascularity and softness of the part at the time, the haemor- rhage and laceration are nearly always more extensive than they were at first. It is impossible to lay down any precise rule as to the length of time required for the repair of these more serious hurts. Each case must be judged on its own merits. The amount of injury, not merely that sustained at the moment, but the sub- sequent damage often inflicted in ill-advised attempts at treat- ment; the kind of tissue that has suffered most; the extent of the extravasation; the particular kind of joint, whether in the upper or the lower limb ; the age, and above all, the constitu- 70 Sprains ; t/ncir Consequences and Treatment. tion of the patient ; the care he will take of himself ; all these things have to be considered with many others before an esti- mate can be given. All that can be said is that a severe sprain, tearing a strong ligament, or wrenching it from the bone, takes quite as long before union is perfect as a fracture through the bone near it. The patient may be able, probably will be able, to make limited use of the limb much earlier, especially if he is careful to avoid any movement calculated to throw a strain on the injured part (which, of course, in the case of a fracture is rarely possible) ; but recovery takes at least as long, and perfect convalescence, with perfect movement, often much longer. CHAPTER VI. IMPERFECT RECOVERY. ONE of the most annoying- things in connection with sprains is the frequency with which they improve up to a certain point and then come to an abrupt standstill. It is not merely that convalescence is protracted, it is delayed so long- that it be- comes a question if the joint is ever to recover. For the first few days, perhaps, everything progresses as well as it possibly can. The patient is wise enough to recognize the situation, and to reconcile himself to the necessary confinement, though this, as only those who have suffered themselves know, is very often far from being an easy matter. The dread of inflamma- tion passes off, the swelling begins to diminish, the color of the skin changes from black and purple to green and yellow, the tender points can be touched again, and a certain range of movement is permitted once more, though in a tentative and cautious manner. With moderate good fortune this continues, until at the end of two or three weeks the injury is repaired, and the joint as sound and as trustworthy as it was before. Verj T often, however, it happens, as time goes on, that the im- provement becomes more and more slow, until, perhaps, it comes to an end altogether, and the joint is left stiff, painful, it may be, and almost useless. The tissues seem to have been repaired, but freedom of movement does not return. The extent to which this suffers differs very considerably. As has been mentioned already, the joint may be merely a little weak and unsteady, not quite to be relied on, perhaps, when called upon for any special effort ; or it may be so stiff and rigid as to give rise to the suspicion that the bones are grown together, and the cavity completely obliterated. It may be perfectly free from all uneasiness in ordinary circum- stances, or it may be the seat of constant aching, with frequent sharp twinges of rheumatic pain. In many cases it may be moved without inconvenience up to a certain point, but the 7 2 Sprains ; their Consequences and Treatment. least attempt to carry it beyond this is stopped at once by pain, and a sense of resistance. Yet, in spite of this, the skin may be quite cool, and the tissues of the joint, to all appear- ance, perfectly sound. Sometimes, in cases such as these, it is possible to find a definite reason ; a tendon may be displaced and have been overlooked, or one of the internal portions thrown out of gear; secondary changes, such as wasting- or spasmodic rigidity, may have made their appearance in the muscles; or the capsule may be so relaxed that it is unable to maintain the necessary degree of pressure on its contents; but such as these, for this reason, must be dealt with by them- selves. Those to which I wish to refer at present are alto- gether different ; no definite lesion is to be found in them ; they do not seem to have been severely injured; there is no evidence that the amount of laceration was extensive ; yet they remain so stiff and painful as to be almost useless, without any ap- parent cause. The severity of the sprain has nothing to do with it. It is quite as common after slight injuries as after severe ones. Indeed, it very rarely follows complete dislocations, in which the laceration is most extensive of all. It may even come on without injury if the joint has been inflamed; no matter how slight the attack, it sometimes leaves behind it a degree of stiffness that lasts for years, long after all trace of the excit- ing cause has passed, and without there being any gross change to explain it. General Appearance. There are certain features about these joints by which they may usually be recognized. If it is a superficial one, like the knee, the skin is reddened, but not with the bright flush of inflammation, or the ruddy glow of use; it is dusky and bluish, and if the finger is pressed upon it so as to drive the color out it is very slow in returning. Often it is cold to the touch ; the patient may declare that it feels warmer than the rest of the limb, and even complain of a con- stant burning pain, but as tested with the hand, or, better still, with a surface thermometer, it is decidedly cooler. Sometimes the skin is smooth and gloosy, sometimes wrinkled, but it does not fall into the natural folds of the part, or glide evenly over the bony prominences beneath. It seems too tight, as if it were shrunken, and it cannot be pinched up, or made to glide from side to side Frequently one or two spots are exquisitely Sprains ; their Consequences and Treatment. 73 tender, not merely when firmly pressed upon, but even if a finger touches the The tissues round are wasted; the shape of the bones stands out too distinctly ; the hollows are not filled in by muscles or by fat as they are in normal health. Even in joints so well covered as the hip and shoulder something- of this can gener- ally be made out by the eye, though measurements may fail. Occasionally, however, this is concealed by the swelling of the subcutaneous tissue round, especially in the case of the ankle joint, if the leg has been allowed to hang down for any time before it is examined. Impairment of Mobility. The most prominent feature, however, in connection with these joints is the interference with their movement. The limb in most may be bent more easily than it can be straightened ; but it is seldom that it can be moved to its full extent in either direction. It is stopped abruptly as soon as a particular angle is reached ; the check is so sudden and so firm that the bones seem locked together, and any attempt to force it further only causes intense pain shooting through the joint, often most severe where the skin is so tender to the touch. Generally, though there is a sense of discomfort and apprehension the joint can be moved up to this point without much distress, but occasionally even this is not possible. The pain is so severe, and the dread so great, that before the part is touched the muscles contract and hold it rigid, almost in spite of the patients' will. It is literally be- yond their power to allow the movement to take place; the pain is to them so intense that their will is overcome and con- trol over their actions lost Muscular Eigidity. In these cases it is impossible to form an opinion without anaesthetics. When the muscles are re- laxed so that their action is eliminated from the question alto- gether, and there is no longer any fear of causing pain, the part may be examined thoroughly, and it is easy to ascertain whether the check is entirely the result of muscular rigidity or whether there is some other obstacle in addition. Such cases are not uncommon. Brodhurst mentions one in which the joint was so stiff and motionless as to give rise to the sus- picion that the bones had actually grown together; when the patient was under an anesthetic, movement was almost as free as it is naturally. 74 Sprains ; their Consequences and Treatment. It is true that a good deal of information may be gained, especially in children, by diverting the patient's attention from the part, and carefully manipulating it at the same time. When this can be done, it is often discovered that the actual range of movement is a great deal wider than it appeared to be ; but, in the first place, this is not always possible ; and then, though the information is undoubtedly of very great service, it is never quite enough. It shows beyond question that the rigidity is due in some degree to muscular contraction ; but it entirely fails to show how much. It is only possible to make certain of this when the muscles are in some way completely relaxed, so that they no longer enter into the question. Creaking. Creaking or grating, as the surfaces move on each other, is always present in these joints. It may be but the faintest sensation of friction, only to be perceived by press- ing the hand firmly on the part, as if two smooth silken sur- faces were being rubbed together; or the noise produced as the fluid is squeezed from one side of the joint to the other may be distinctly audible to those around. This, of course, depends on the condition of the lining membrane of the cavity, whether it has merely lost the polish from its surface or is covered over with folds and fringes, which project from all round the margin into the interior. Bands and Adhesions. It is a matter of popular belief that there is in these joints a band of some kind, passing across the cavity from one side to the other, independently of the lining membrane. When at rest this is quite loose; as the limb moves it suddenly becomes tense, and stops it abruptly, causing very severe pain by the way in which it is stretched. It is possible, of course, that a structure of this kind is devel- oped sometimes; but I have never found such a one myself in a joint, nor am I aware of any case in which such a phenomenon has been recorded. Its presence would undoubtedly furnish a very simple explanation of symptoms that are often obscure ; but it possesses the objection of being almost too simple. It explains all the facts at once, in such a plain and straightfor- ward manner, that in the absence of all corroborative proof, one cannot but feel a certain degree of scepticism and reluct- ance in accepting it. At the same time it cannot be denied that the evidence on which this opinion is based is very striking, and is sadly in Sprains ; their Consequences and Treatment. 75 want of an explanation. A joint has been sprained some long- time before, and for years has remained painful, and, compar- atively speaking-, useless; it has been rested, and bandaged, and blistered over and over again without the least benefit; any attempt to move it is slopped at once by the pain; every time it is tried it becomes swollen, hot, and tender; and ap- parently drifts down into a worse condition than it was before. All of a sudden, something gives way, perhaps with an audible snap ; there is a moment's intense pain ; but movement is re- gained, and recovery is perfect from that instant, without after trouble or ill consquence of any kind. A good many cases such as this have been recorded from time to time, among others by medical men, from their own personal experience. Sometimes they have been cured by a designed plan of manipulation, sometimes by an accidental fall. There is, however, a certain amount of suspicion that they are not quite so cotamon as is generally believed, for it is in the nature of people to spread abroad as widely as they can everything that savors of the marvellous. I have mj-self met with very few that could be called in any way typical, though, of course, instances of joint disease, in which great improve- ment has resulted from vigorous passive motion, are common enough. One instance was very characteristic. The patient was a strong, healthy man on active service, who had been in- valided home owing to the condition of his knee. (I may remark that a very large proportion of the more striking cases occur in connection with this joint.) He had sprained it severely some months before in a fall from his horse, and as it was con- siderable time before anything could be done for him the swelling became enormous. Then it was kept absolutely quiet in a straight position for three weeks. Cold was applied, but not compression. At the end of that time the joint was ex- ceedingly stiff and painful, but still he managed to get about upon it, and it improved gradually, up to a certain point. It could be straightened out fairly well, but could only be bent through about twenty degrees; as soon as this angle was reached it came to a dead stop, and any attempt to carry it further only caused the most intense pain and made the swell- ing worse. At the time that I saw him he was so disabled that he was only able to go upstairs with difficulty. The joint was very slightly swollen; so far as could be detected nothing 76 Sprains ; their Consequences and Treatment was out of place. All that could be found was a very tender spot on the inner side of the knee-cap, where the pain was always most intense. Circumstances at the time rendered it unadvisable that an anaesthetic should be administered, and a few days after he was completely cured by an accident. Coming- downstairs he tripped suddenly, throwing- involuntarily the whole of his weight on the affected limb, felt something snap, and fainted away from the pain. When he recovered the joint was a little tender over the old spot, but it could be moved as freely as the other. There was no increase in the amount of the swelling, and the pain was gone, nor did it re- turn. (Strange cures of this description are not limited to sprains, as the following extract shows : " Persons given to meditation must often have found ample material for specula- tion in endeavoring- to imagine what train of thought could have prompted the introduction of certain surgical procedures, or led to the first trial of this or that therapeutical agent in the treatment of a particular disease. What, for example, could have stimulated the first idea of curing- sciatica by stretching- the sciatic nerve; certainly the task of finding- a train of thought which should conduct to that conclusion would be a severe one. Many such methods have doubtless been sug- g-ested by a real or fancied analogy between them and certain natural accidental occurrences, and in this sort of observation charlatans in all ag-es have shown themselves singularly apt. We may quote a couple of instances of recent occurrence, where the cure was effected under circumstances which must have sug-gested to bone-shakers their violent and unscientific, but occasionally successful manipulations. In one case the person had been almost bedridden for many weeks from sciatica; still suffering- acutely from the attack, but a trifle less in pain, he hobbled forth to g-et the benefit of a little fresh air ; at a cross- ing he was roughly pushed by a passing- vehicle, and after a desperate but unavailing- effort to preserve his equilibrium he fell on the road in the midst of a fairly dense traffic. It was only when he had regained the sidewalk that he began to feel astonishment at the, in him, remarkable agility shown in jumping- up and running to a place of safety. The sciatica had quite disappeared, and had not returned four years later. In case number two a strain had been followed by severe pain on movement over the outer condyle of the right elbow, which Sprains ; their Consequences and Treatment. jj lasted for several months, almost incapacitating 1 the sufferer from pursuing 1 his occupation as a hairdresser. There was no obvious lesion, but no treatment was attended with any bene- fit. One night, on leaving work, he had to find his way along- a dark passage, in which the cellar door had inadvertently been left open. Against this he struck himself violently on the painful spot, giving rise to such pain that he nearly fainted. Within a day or two, however, as the effects of the bruise dis- appeared, the other pain was now noticed to be absent. The facts are rather curious, although it must be confessed it is not easy to see how to formulate any practical rules of treat- ment as a deduction therefrom/') It certainly seems possible that in this case a band was de- veloped in connection with the joint during the long period of repose, but I am not prepared to assert that it was in the in- terior of the sac. The tissues were very much swollen for a longtime after the accident; the joint was never moved; a great deal of effusion was thrown out ; the soft folds that exist round the knee-cap were immensely thickened, so that it is possible they gradually formed a connection along the interior of the capsule with those of the opposite side ; as organization proceeded the union gradually increased in strength, until it was firm enough to check the movement of the joint: strain- ing on it caused severe pain by the way it dragged upon the softer tissues; the sudden violent jerk tore it in two, and re- stored free movement. But it must be admitted that this does not rest on any direct or certain evidence. Changes in the Tissues. Opportunities for examining the interior of these joints must, from the very nature of things, be quite exceptional ; and the difficulty of explaining the symp- toms is not diminished by the fact that when one does occur the result is not always unequivocal. In a large proportion there is nothing to be found post-mortem ; the structures ap- pear as sound and as healthy as could be wished ; and even where there is something definitely wrong, it is often so slight that it is impossible to believe symptoms of such intensity could be due to it alone. Clearly, the conditions upon which they depend must, in the majority of cases, be such that they come to an end, and disappear with the life of the part. Nor is it difficult to imagine of what sort and kind they must be. Changes in the circulation or nutrition of the tissues, for ex- 78 Sprains ; their Consequences and Treatment. ample, often leave no trace behind, and yet may cause the most serious interference with the way in which the work is carried out. It is quite enough if the part is imperfectly sup- plied with blood so that the muscles are overloaded with waste products, and the nerves enfeebled and unable to play their part with sufficient energy. There need be no actual change apparent to our present methods of investigation ; the tissues may be merely stiffened from disuse and badly nourished, un- able to move freely, or accommodate themselves to each other; there is no need of more, it is quite sufficient, without having to invoke the aid of conspicuous alterations in structure. The Interior of the Joint. Sometimes there is an excess of fluid in the interior; more often, especialty if the joint has been kept at rest for long, the quantity is diminished, and it is nearly always thin and serous in character, a little turbid, and not so oily as it should be. The cartilages are never much affected, the part they play is too passive, only in old and long- standing cases they lose the glistening polish from their sur- face, and are a little thinned. The capsule, with the loose tis sue round, as a rule, shows more; instead of being soft and flexible, so that it falls into folds as the joint moves in one direction, and opens out again as it moves in the other, it is stiff and unyielding. In other cases it is irregularly thickened, with its inner surface marked by folds and ridges, in which are little elevations of 'the lining membrane; or at the point where it is attached to the bone, and the fibres diverge some- what from each other, there is an accumulation of lymph hold- ing them together, and as it becomes organized making one part drag unfairly and unevenly on the rest ; or, again, there is an old extravasation of blood, the remains of some larger quantity, of which part has never been reabsorbed. Old Extravasations in the Wall. In one case, at least, I think I could attribute the whole of the symptoms to a cause of this kind. The patient was a man of more than middle age, who came to me complaining of an exceedingly painful and tender spot over the inner side of the knee joint, about half an inch from the margin of the knee-cap. There was a history of his having struck the joint against a sharp piece of furni- ture on this particular spot some weeks before. The skin itself was freely movable, but appeared slightly raised and puffy; there was no dislocation at the time that I saw him, and it Sprains ; their Consequences and Treatment. 79 was doubtful if there had been any at least, the patient had not noticed it. The pain on touching- it was intense; steady pressure could hardly be borne at first, but seemed to relieve it afterward; walking-, particularly going upstairs, and set- ting the extensor muscle of the leg in action, were both very painful. With the joint itself there seemed to be nothing wrong; there was no appreciable excess of fluid, and the ten- der spot was so fixed, that, almost certainly, it had nothing to do with the formation of any fringes or foreign bodies in the interior. The suggestion was that either some of the fibres of the muscle inserted into the capsule had given way, or that there had been a small haemorrhage into the substance of the capsule itself. I had the opportunity of examining the joint at a later period, and was able to verify the diagnosis; so far as I could ascertain the muscular fibres were intact ; in the substance of the synovia! membrane, corresponding to the painful spot, there was a small hard mass projecting further into the cavity than it did on the exterior, probably because there was least resistance in this direction. It seemed to be the residue of an old extravasation ; the blood had been effused between the fibres of the capsule; some of it had been absorbed; the rest, owing- to the protection it received from the side of the knee-cap, escaping all pressure, had become organized and formed a small hard nodule. Probably this happens in many cases without material consequence; most likely in this par- ticular one it implicated in some way or other a nerve filament, and, like the little peculiar tumors known as painful subcu- taneous tubercles, when it was touched it dragged or pressed on the nerve and gave rise to stabs of acute pain. Dry Synovitis. Barwell has described under the name of dry synovitis, another condition which may exist in some of these cases, and help, in a measure, to account for the symp- toms. There is, according to him, a deposit of fibrinous mate- rial on the inner surface of certain parts of the lining mem- brane, probably derived from the fluid which collects in the joint when it is inflamed. During life these spots are so painful that the patient will hardly allow them to be touched, and can scarcely be persuaded to move the limb. Sometimes the pain is paroxysmal, arid often periodic in character, and it is always severe to a degree which bears no comparison with that of ordinary synovitis. 8o Sprains ; their Consequences and Treatment. Neuralgia. Occasionally the pain and loss of power are caused by a kind of neuralgia, which attacks joints and seri- ously interferes with their freedom of action, without leaving behind any visible evidence of its existence. These may be recognized by the peculiar periodic character of the pain, and by the way in which it is limited to certain spots, which cor- respond fairly well to the places where the nerves penetrate the fibrous capsule. The skin immediately over them is ex- quisitely tender to the touch, and sometimes puffy, or slightly swollen; and movement is limited, because, as the joint bends, the capsule is exposed to different degrees of tension, and in certain positions the affected nerve is pressed upon or stretched. The check, however, in these is rarely so abrupt as it is in the others. In one case under my care it appeared to alternate with supraorbital neuralgia, the pain sometimes occurring in one locality, sometimes in the other, but scarcely ever being present in both at the same time. The patient, who was thoroughly overworked, was readily cured by rest and change of scene. Tissue Starvation. In a large number, however, this ex- planation fails as well. There is no evidence of neuralgia ; there is no gross lesion to be detected anywhere; no increased effusion, thickening, or adhesion; the tissues simply are wasted; the muscles have lost their power, and the joint is so stiff and painful that it is almost useless. The real reason is the prolonged want of use. The tissues are starved and badly nourished. During life they are surrounded and bathed in a nutritive fluid, which pours out through the walls of the vessels and permeates them in all directions. It spreads every- where in the interstices, giving up to the structures with which it comes in contact the material they require for their growth and action, and taking away whatever is worn out. The sur- plus is drained off by a special system of vessels, the absorb- ents, so that it may never remain stagnant. The rapidity of its flow is entirely regulated by the activity of the tissues. If they are in constant use, a larger amount of blood comes to them; more of this plasma passes through the walls of the vessels into the spaces round ; the supply of nutritive material is greater, and the waste more rapidly carried off. If, on the other hand, the part is kept in a condition of absolute repose, the plasma lies stagnant round and between the tissue ele- Sprains; their Consequences and Treatment, Si ments, so that when they are suddenly called upon for active work they are unfitted and unable. Until the free current of the plasma is thoroughly re-established once more, recovery of power is impossible. When this is effected the parts regain their strength and vigor almost of themselves. Even a healthy joint that is kept absolutely at rest may be so badly nourished that it becomes stiff and unfitted for work, especially if the demand is urgent or severe. If it has been injured or inflamed, so that there is a larger amount of waste and greater need for repair, and is then kept motionless, this result is almost certain to occur. It is a common thing to call such joints as these hysterical, merely because there is no evidence of any gross or conspicu- ous lesion ; nothing, for example, is out of place, and no band or adhesion can be detected. But it is more than doubtful how far this is correct. "When a joint becomes stiff, and the muscles wasted because they have been disused and are not properly nourished, it ceases to be purely and simply hyster- ical. It is true this may have been the starting-point, because of this the joint may have been kept at rest or prevented from enjoying its full range and freedom of action; but when changes of this description have once made their appearance there is something above and beyond mere hysteria. There is a local affection which can only be cured by local measures, and which must be cured before the hysterical condition can disappear. So long as it persists the patient is convinced, and quite rightly convinced, that the joint cannot be used freely as it ought to be. It is quite true that it cannot, and until it has regained its freedom of action, and the muscles their strength, it is hopeless trying to convince the patient that it can. Hap- pily in many instances the changes are so slight that the joint recovers if it is only used in a moderate degree ; if, for example, under the influence of change of air, or change of interest, the patient's attention can be diverted from it. Often, however, this is not enough, and then measures must be taken, first to give back to the joint its complete range of movement, and then to restore the nutrition of its tissues so that they may regain their power and activity. OHAPTEE VII. TREATMENT. COLD. HEAT. PRESSURE. IT must be admitted there is something- very unsatisfactory in the results obtained by the ordinary methods of treatment. Even when the greatest care is taken, when every precaution is used, tedious convalescence is the rule, rapid and perfect re- covery the exception, and often, owing' to carelessness or delay, the joint never recovers at all. It is left weak or tender, not so trustworthy as it was ; prone to SAvelling- with the least ex- ertion, and sensible to every chang-e of weather, so that there is an end once and for all to the healthy unconsciousness that such a thing as a joint exists. The reason is not far to seek. In a large proportion of cases the measures adopted are altogether insufficient; in some they are absolutely wrong-, when, for example, a joint is kept perfectly quiet until it becomes hopelessly stiff; while in nearly all the time that is of the greatest value, that which immedi- ately follows the accident, is allowed to pass by without any- thing- being- done, and completely wasted. Whatever plan is adopted it is essential to beg-in at once. Every moment lost makes a serious difference. The injury is not confined to the instant of the accident. The blood keeps pouring- out from the wounded vessels and accumulates in the synovial sac and the interstices of the tissues, until if left to itself it causes such an amount of pain and tension that in- flammation is bound to follow. If recovery is to be speedy or sound this must be stopped at once, or, at any rate, confined within the narrowest limits. When once it has left the ves- sels, and become extravasated, it serves no useful purpose, whether it collects in the cavity of a joint or spreads itself through the loose tissues of the limb. It separates the ends of the torn lig-aments; it distends the synovial sac until it be- comes stretched out of all proportions, and when it is absorbed Sprains ; their Consequences and Treatment. 83 it leaves the capsule loose and flaccid, so that the joint feels weak and powerless. If it remains, the consequences are worse still ; either it breaks down and forms an abscess, or; as already described, becomes organized into a hard unyielding 1 mass, which interferes with the action of the muscles and compresses the nerves so that free use of the limb is rendered impossible. The first thing to be done then is to check the bleeding into the tissues, and to spread out over as large an area as possible the fluid that has escaped already. Then, as reaction sets in, as the part becomes warm and red, and as the quantity of blood circulating through the uninjured vessels begins to increase, steps must be taken to keep this well within bounds. There must be a certain increase; it is essential for repair; the injury entails more work; there is a larger quantity of worn-out material to be removed and replaced, and more blood is required for it. Only it must be kept strictly within limits, and not allowed to run on until the synovial sac and tendon sheaths become distended or inflammation itself sets in. If this can be done little further is required. All that re- mains is to assist the circulation through the tissues in every way, to maintain the nutrition at its highest level, and by gentle passive motion prevent the limb becoming stiff. Repair takes place with very different rapidity in different people and in different ages, but ligaments that have given way, or that have sustained many small injuries in their substance, natu- rally cannot in any circumstances be repaired at once. Cold. When the matter is thought out there is something almost ludicrous, if such serious consequences did not follow, in the general way in which, as a matter of routine, a wet bandage is applied to a sprained ankle. For the moment it is cool and pleasant, and with the folds and turns lying evenly and smoothly on each other, looks exceedingly neat. The uniform pressure does give relief at first, but in a very few minutes the coolness disappears and the temperature is as high as that of the joint beneath. In a few more it begins to dry, and as it dries it becomes loose, so that the pressure (which never at any time falls quite in the right part) disap- pears altogether. If the bandage is removed and the limb ex- amined it is smooth and round, with the hollows quite filled up. The bandage, of course, passes over them without press- ing upon them, reserving this for the bony prominences which 84 Sprains ; their Consequences and Treatment. do not require it. The soft tissues are swollen and cedema- tous, and the sy no vial sac and the tendon sheaths distended with fluid. ' Applying it again in the same fashion does no good, nor is it of any use keeping the bandage wet. The prin- ciple is correct, but the method of application altogether a fail- ure. Neither the cold nor the pressure is applied effectually, and the result of this method of treatment may be seen in the fullness and swelling that persist round ankles for years after they have been sprained. The fault is not that of the cold. This is one of the most useful and satisfactory applications known. It may be dry or moist; it does not matter how it is obtained. The limb may be surrounded with ice or cold spring water poured over it, or it may be immersed in the water, or any other method adopted that suggests itself at the moment. The important point is that it should be applied at once, and that the limb should not be allowed to recover its temperature until a more permanent application is ready. Used in this way, as a first agent, cold is simply invaluable. It is always at hand, any one can apply it, and it fulfills every indication. The blood-vessels contract at once, the skin becomes white, the bleeding is checked, the sensitiveness to pain is diminished, and the tendency to swell- ing very much lessened. If, however, it is used in a hap-hazard sort of way, as it is under a wet bandage, if the limb is allowed to grow warm from time to time, the whole of the benefit is lost. Reaction follows as the effect passes off; the blood-vessels dilate again until their diameter is much larger than it was before. More blood flows through the skin and the adjacent parts; a larger quantity pours out where the vessels are torn; the temperature rises; the sensitiveness of the skin is increased; it begins to glow, and the patient becomes conscious that the joint is increasing in size. In reality more harm is done in this way than if the the part is left entirely to itself. In some people who are more than usually susceptible, it is enough to produce results of exactly the opposite character to those intended, and in the later stages of sprains, when the joint is cold and powerless, it is used in this way for this very purpose. The alternate action of cold and w^armth is one of the most effectual meas- ures known for stimulating the circulation through a part, and if employed soon after the infliction of such an injury as Sprains ; their Consequences and Treatment. 85 a sprain, before the ends of the vessels have had time to close, certainly does more harm than good. As a Temporary Application. It is equally important that the application should not be continued too long 1 . As an immediate and temporary expedient cold can scarcety be sur- passed, but after a time a condition of passive congestion sets in. The nerves and the delicate muscular fibres on which the contraction of the vessels depends become paralyzed; the part becomes red and swollen, in great measure from the blood that lies stagnant in it ; the skin is anaemic, shrunken, and rough from the upstanding papilla?; the amount of blood and lymph in the tissues is sufficient, but it is never changed ; the vitality of the part is lowered; the nutritive changes on which repair depends are carried on more feebly, and if the process is con- tinued may stop altogether, so that the part either actually perishes or is attacked by a IOAV form of inflammation. Even when the effect falls far short of this, long-continued cold brings about a state of things in the tissues that is by no means favorable to the repair of injury. Method of Application. Cold may be applied hi a multi- tude of ways, but as a rule the simpler the method the better. It may be dry or moist. In the former case it acts by con- duction only; in the latter by evaporation as well, but it is possible this advantage is more apparent than real. It is much more important that time should not be lost, and that the injured limb, especially if it is the ankle, should not be allowed to hang down, as it nearly always is. In some parts of the body, such as the hip, there is no doubt of the superior comfort of the dry method ; in others the position in which the limb must be placed, and the facility with which the cold can be applied, form the best guide. Cold spring water is nearly always at hand. It may be either poured freely over the injured part, or this may be im- mersed in it. The former plan is the more efficacious; inde- pendently of the fact that fresh quantities of water are contin- ually being brought into contact with the skin and abstracting heat from it, and that a certain amount of evaporation can take place as well, it is probable that the actual impact of the calling water, perhaps by the shock and the influence it has on the nerves in making the vessels contract, perhaps by the force of its fall, is of great assistance. As soon as the joint 86 Sprains ; their Consequences and Treatment. ceases to swell and the skin is beginning- to look dull and livid, the maximum amount of benefit has been produced. It is rarely advisable (at any rate, if pressure can be applied) to carry it any further. The same effect may be produced by immersion, but unless the water is very cold it is much more slow, probably because the layer next to the skin is soon warmed to the temperature of the body. If ice can be obtained at once in sufficient quantity, the result is as rapid, but there is the disadvantage that it is nearly always necessary to allow the limb to hang down, a position which should always be avoided, as it tends to increase the amount of blood in the part, and sometimes makes it much more painful. Continuous Application. A few days after the accident, if by any mischance inflammation does set in, cold may be applied continuously, but then the reason is not the same. In these circumstances it may be kept up for an indefinite length of time. The object is to diminish the amount of blood circu- lating through the part, and so to lower the temperature and reduce the inflammation. But in sprains, ordinarily speaking, there is not any inflammation to reduce. As Hood and many others have pointed out, .there is absolutely no reason why, when a sprain occurs in a healthy person, and is treated with a reasonable amount of care, this complication should set in more often than it does in the case of simple fracture. The most convenient fashion for its continuous application is by a set of Leiter's coils. They may readily be improvised out of India-rubber tubing (the best is that which has an internal diameter of about one-third of an inch and moderately thin walls), or better still from composition gas-piping, which has the advantage of retaining the shape to which it is bent. They may be applied to any part of the body, coiled round a limb, for example, without the circles being in any way fastened to- gether, or wound in a flat spiral and rested on the part, as in the groin, or pressed into the shape of a low cone and arranged to fit the shoulder. All that is necessary is that there should be two buckets, one containing water of the desired tempera- ture placed on a stool a little higher than the limb, and con- nected with one end of the coil by means of a piece of tubing ; the other, on a lower level, empty, and connected with the other end. As soon as the current is started from one to the Sprains ; their Consequences and Treatment. 87 other the flow is continuous, and may be regulated with the greatest accuracy. It is not essential that the cold should be confined strictly to the part actually inflamed. If an ice-bag- is laid on a limb over the course of one of the main arteries it causes a very sensible diminution in the temperature of the part below by the constriction it induces, and by the propor- tionate diminution in the amount of blood. There are other methods as efficacious, but less convenient. One depends on the well-known fact that if a skein of wool is allowed to hang over the edge of a vessel, so that one end dips in the fluid inside and the other hangs over the edge, a continu- ous stream of drops will come from the dependent half until all the fluid is gone. A drip pot of this kind, or more than one, suspended over a limb and filled with evaporating lotion reduces the temperature quite far enough. Iced water, or a lotion containing chloride of ammonium in solution, answers very well, but if the full effect is desired there is nothing to equal lead lotion mixed with spirit, and containing a few frag- ments of ice. The effect is greater in proportion to the amount and strength of the spirit. It may be allowed to drip on to the skin directly, or this may be covered with a single thick- ness of lint, so as to avoid splashing, and to carry off the surplus fluid. If the lint is folded even once, so that there are two layers, evaporation is checked to a considerable extent, and a great deal of the effect lost. Arnica, which is frequently recommended in the early stages of sprains, is worse than useless. The sole merit that it pos- sesses is due to the spirit that is mixed with it, and it has the very serious defect of exciting in many people (especially when it is not very much diluted) a peculiar form of inflam- mation of the skin, which is not only very difficult to distin- guish from erysipelas, but which is very likely to run on into it. Aconite, too, may be mentioned here as occasionally of service when one or two small spots are exceedingly tender, but care must be taken, especially when it is mixed with chloroform, that it is not applied over too large a surface. A still more simple wa.y of applying cold is to fill an India- rubber bag (or where this is not handy an ordinary bladder answers all the purpose) with small fragments of ice, or with ice and salt, and to allow it to hang over the joint so as just to be in contact with it. A double fold of lint, or a thin 88 Sprains ; their Consequences and Treatment. pocket-handkerchief, must be placed underneath, lying- on the skin and changed occasionally, as it soon becomes wet from the condensation of moist air on the outside of the bag-. This plan is particularly useful when it is desirable to produce an effect on deep-lying- structures, or to keep the cold up for a considerable leng-th of time, as it is very effectual, may be graduated exactly, does not want watching, and makes no mess. Cold is most successful in sprains of large joints when the swelling comes on rapidly. If twelve or more hours pass by before this makes its appearance, pressure applied early an- swers a great deal better, though even then, if a joint such as the knee or ankle has been bandaged carefully, an ice-bag laid on it makes its influence felt, and helps to relieve the feeling of tension and throbbing. When the brunt of the injury is borne by the muscles it is not nearly so serviceable. In the aged, in the very young, in those subject to local congestions such as chilblains, and in the rheumatic, it must be used with great caution, and the skin, if it is moistened, must be dried with the greatest care; otherwise it may happen that the de- pression due to the cold insensibly shades off into an attack of inflammation, the very thing it is intended to prevent. Heat. Heat may be employed in many cases in which the use of cold does not seem advisable. Its value as an immediate application depends on the fact, which is not so widely known as it might be, that hot water, if the temperature is suffi- ciently high, is as effectual in stopping bleeding as ice. The skin becomes cold, the vessels in it and in the layer immedi- ately beneath contract, and the circulation in many instances almost stops. In the case of the fingers, where in proportion to their thickness the extent of surface is very great, I have seen complete blanching and numbness produced by dipping the hand into very hot water, and have known it last even in the hot days of summer for many hours, longer than if it had been due to the application of ice. To produce such an effect as this the temperature of the water must be as hot as can be borne. It cannot, therefore, be kept up for more than a few moments, for fear the skin may be injured ; and for the same reason it cannot be em- ployed, as cold is, to diminish the calibre of the vessels in the deeper -lying structures. Its value is greatest when the in- Sprains ; their Consequences and Treatment. 80 jured part lies near the surface, particularly in the case of tendons, which, like those on the back of the hand, run a long- distance down into the fingers, tying- immediately under the skin the whole way. In the ankle and elbow, also, it succeeds fairly well, but the difficulty of application in the case of other joints is so great that it is generally better to rely on cold. The temperature of the water requires a good deal of judg- ment, especially as different people, even different parts of the body, vary very much in their degree of tolerance. With children, it is particularly necessary to be careful, as their skin is so delicate. Happily in them joint sprains are not so common as they are in adults. The fingers can stand a higher temperature than the hand, and this, again, a much higher one than the elbow; indeed, the point of the elbow is, so far as heat is concerned, one of the most sensitive parts of the body. The extent of surface immersed has to be considered, too. It must not be forgotten that the sensitiveness to heat increases with the area exposed. It is not a bad plan to place the limb in hot water, and then raise the temperature rapidly by adding more, until it is as high as the patient can stand, taking care to stir it round all the while, so as to dis- tribute the heat evenly through the whole. Two or three minutes ought to be sufficient ; often the full effect is gained at the end of the first. Heat used in this way has a wonderful power of relieving pain. The skin may not be blanched, but its sensitiveness is lowered ; manipulation is more easy, and displaced tendons or other structures can be restored to their position without the sickening sense of over-stretched fibrous tissue. It is worth noting, moreover, as another point in its favor, that the effects are more lasting than those of cold, and consequently time is gained for the application of other and more perma- nent measures, such as massage and bandaging. Sometimes, after prolonged overwork or severe strains, the bony prominences to w T hich the muscles are attached become sore and tender, or the tendon sheaths seem to be roughened and uneven, so that perfect smoothness of motion is lost; or in certain classes of work, where without the actual exertion being great, rapidity and delicacy of movement are carried to a very high pitch, the nerves become painful, and the muscles liable to sudden and spasmodic contractions. When this oc- 9 Sprains ; their Consequences and Treatment, curs the prolonged application of warmth may generally be relied upon to give relief, at any rate for a time. A moderate temperature usually suffices. The object is not to numb the sensibility of the part, but rather to relax the walls of the vessels and relieve the tension, so that blood may circulate more freely through the tissues, and the delicate fibres, in which the nerves end, may no longer be kept upon the stretch. This holds good even when some of the muscular fibres have been torn across or rent from their attachments. Later, when the joint is beginning to recover and movement is returning, heat is of value both for its own merits and as a preliminary to massage. There is then no limit to the length of time it may be applied. The hand, for example, if it is stiff from the effects of some old sprain, may be kept soaking for hours in water as hot as can be borne with the greatest benefit. The tissues become soft, everything is supple and flexible, the constant aching disappears, and movements which before were out of the question are executed with ease and freedom ; only, unfortunately, it rarely happens that the whole of the improvement is retained. So far as stiffened joints, at least, are concerned, it does not seem' improbable that the reputation enjoyed by many of the foreign baths is due more to the temperature of the water and the length of time the limbs are allowed to steep in it than to anything else, though it is not denied that in other respects they may be of consid- erable service. Besides these there are other methods, less general in their application, which are better described in the treatment of special sprains. Ironing, for example, is often of great use where large masses of muscle in the loins are stiff and painful from overwork or cold, so that the patient cannot move with freedom or even hold himself erect; and hot vapor or mud baths, where the limbs are stiff and crippled from old attacks of inflammation, frequently procure great relief from pain; but remedies of this description must be dealt with by them- selves. As a rule, they are used in conjunction with others, and do not depend for their merit on heat alone. Heat and Cold Alternately. Later still, when the repair of the tissues is perfect, but full use is not restored, nothing can be more successful than the alternate action of heat and cold. Some weeks, perhaps, have passed since the joint was Sprains ; their Consequences and Treatment. 91 hurt; all fear of inflammation has been dispelled; there is nothing 1 out of place; no bands or adhesions to hurt the move- ment; no very tender spot, though the whole may ache, es- pecially after it has been used; but there is no power in it. The joint is colder than its fellow ; the skin is livid and wrinkled, fitting- closely on to the bones, and often sligiitly swollen where it stretches over the hollows between them ; the position of the parts is natural and good; one bone can be moved upon the other, though, perhaps, not quite to its full extent ; but the part looks and feels as if it were only half alive, able to put out half the energy it should. Sometimes, it is true, this is the result of defective energy and will in the great nerve centres, but often the fault lies in the part itself. The tissues round the joint have been at rest so long, have been so long without doing anything for themselves, that they have almost lost the power. The circulation through them has been at its lowest ebb for such a length of time, that when a sudden demand is made upon it it is unable to respond. In these circumstances the shock of alternate heat and cold acts as a most powerful stimulus, especially when used in the form of a douche, pro- jected with some force and suddenness against a part which has been allowed to soak in hot water. The skin, of course, receives the greatest amount of effect, and sometimes, espe- cially with the needle douche, a great deal more has been done than was desirable ; but the whole circulation through the part is quickened; the volume of blood increases; the nutrition of the tissues is carried on more as it is in normal health, and the muscles and nerves begin at once to regain their power. Aided by galvanism and other measures, it is surprising how this method of treatment restores tone to the muscles, and causes the absorption of chronic exudations that perhaps have remained passive and unaltered for years; only, partly from the very ease with which it may be applied, it is not advisa- ble that this line of treatment should be carried out without suitable supervision ; or more harm than good may easily be done. Pressure. This is not the only plan which illustrates the value of a time-honored practice, when carried out thoroughly, and its worthlessness as usually employed. Bandaging for sprains is almost universal, and well deserves its reputation ; it must be carried out systematically and rationally, with 9 2 Sprains; their Consequences and Treatment. a proper regard to the structure of the joint, the arrangement of the parts round it, and the movements it ought to perform ; and this implies anatomical and surgical knowledge of no mean order. Heat and cold are only of temporary use; their influence on the vessels is exerted through the nerves and muscles, and after a time these, like other vital structures, become tired out, relax, and give way. Both of them when continued too long help to produce the very effect they are intended to prevent. The tissues become congested; the circulation is checked, though the actual amount of blood in the part may even be greater than normal; the cavity of the joint is distended; and the soft tissues round and between the bony prominences are filled with exudation, which becomes organized, develops into tough and unyielding fibrous bands, and cripples the move- ment of the joint in all directions. As compared with these the action of pressure is entirely mechanical; the measure may be graduated according to the needs of each case, and it may be kept up at any required de- gree for an indefinite period of time. When carefully and methodically applied, nothing can be more efficient for stopping bleeding, or for insuring the absorption and dispersal of blood that has escaped already. It controls the hypersemia and checks the dilatation of the vessels, so that the outpouring of the plasma into the tissues is restrained within proper limits. It prevents the accumulation of fluid in the synovial cavities; assists the absorption of plasma from protected spots, so that it neither runs on to inflammatory exudation on the one hand, nor becomes organized and leads to stiffening of the joint on the other; and above all it relieves pain in the most wonderful way, whether it is the sharp and acute kind that comes on immediately after an accident, due to the stretching and tear- ing of the nerves in the ligaments and fibrous structures, or the dull aching afterward caused by the continued tension on the capsule. In the majority of instances, if compression is properly applied, the swelling disappears by the next day, and the joint may be moved through nearly its whole range with- out more than a sense of discomfort. Method. To bring about this result, however, the com- pression must be applied with a definite knowledge of what is desired, and how it is to be obtained. Merely putting a band- Sprains ; their Consequences and Treatment. 93 age on a limb that has been sprained is only liable to perpet- uate the very evil it is intended to prevent. It may be commenced at once, as soon after the accident as practicable, or heat or cold, as the case may indicate, may be applied for a short time first. Probably in most cases the latter plan is the better; heat or cold requires less skill, and relief from pain is attained more immediately, while, if carried out effectually, time is not really lost. Besides, before a bandage can be applied, it is necessary to make perfectly certain that there is no displacement of any kind. If there is anything- of the sort it must be made out and rectified before further steps are taken ; it is hopeless trying to cure a sprained joint if any of the structures belonging- to it are out of their natural position. How far it may be advisable in these cir- cumstances to make use of massage as a preliminary, is a question that is best dealt with by itself. The method of application is all important, though the rules that guide it are sufficiently simple. The joint must be fixed in the most suitable position, not necessarily the one se- lected by the patient. For example, in sprains of the ankle the foot should be at right angles with the leg; when the knee is injured the joint should be slightly bent, though not nearly to the degree in which the patient is almost sure to place it, and the arm should hang by the side when the shoulder is involved. The pressure must be applied so that it falls only on the parts that require it, not on the bony prominences, that is to say, but over the tendon sheaths, and on the masses of soft and delicate tissue that fill up the interspace between them and the bones, especially on the inner side of the limb. It must be smooth, even, and well graduated, commencing from below, and working upward toward the trunk, and it must possess a certain amount of elasticity, so that as the swelling diminishes under its influence the bandage may still keep up some degree of compression. For this purpose there is nothing more suitable, and, fortu- nately, nothing more easily obtained, than ordinary cotton wool. Pads may be made of this to fit into any depression, no matter how small, and, if not too firmly compressed, they keep up an even and equable amount of pressure, even when absorption underneath has effected a considerable difference in the size of the limb. Failing this, the next most useful sub- 94 Sprains; their Consequences and Treatment. stance is a firm and fine-textured sponge. This may be made into pads which admit of the most perfect adjustment as re- gards size, shape, and thickness, and it is more easy to keep them in their proper place when the limb is being- bandaged. Many other substances, however, serve on special occasions; dried moss, for instance, forms a capital substitute, and I have known even seaweed tried with success. Some of the thicker and softer kinds of felt make admirable pads, firm and soft, yet quite elastic, and capable, if several layers are sewn to gether, of being modeled into any shape. Sometimes this firmness is of especial service. I have employed them with great advantage in sprains of the extensor tendons on the back of the wrist, when the distention has not been very great, but where there has been a large amount of creaking or grat- ing on movement. It is difficult here to adjust pads of cotton wool sufficiently accurately, while the felt is easily shaped to suit the varying thickness of the soft parts. The pressure is distributed evenly over the whole length; the tendons are kept at rest ; and the firm compression insures the rapid disappear- ance of the exudation. Pads of sponge or felt may, moreover, be soaked in lotions, if it is considered advisable, without altogether destroying their elasticity. I have not found much occasion to put this into practice, but once or twice, when the pain over small joints was very severe, the application of a lotion containing a solution of morphia afforded great relief. Of course, a cer- tain amount of caution must be used. A thick felt pad, covered on the outer side with a layer of some waterproof material, is capable of taking up no inconsiderable quantity, but the area of the pad is generally small, and the condition of the parts beneath is not one adapted for rapid absorption. If there is the least abrasion this caution is particularly required. It is impossible to be too careful in molding the pads to the proper shape of the limb. In the case of the ankle, for ex- ample, where the joint alone is involved, the swelling shows itself on the front, lifting up the tendons that run down to the toes, and behind on either side of the tendo-Achillis, filling up the natural hollows there, and reaching up the leg higher on the inner side than the outer. Over the malleoli, of course, there is none, and, unless the injury has been so severe as to tear the ligaments, scarcely any is perceptible along their Sprains ; their Consequences and Treatment. 95 lower border. This may be complicated by the distention of some or all of the tendon sheaths that run down on either side; and if some few hours have been allowed to pass by, there is, in addition, a great deal of thickening- in the loose and delicate tissue that fills up the interstices between the skin and the tendons, and the tendons and the bone. The swelling may reach down far on to the foot, and almost to the knee. All this must be made out; and the natural contour of the limb seen, as it were, through the swelling, before the pads can be shaped and the bandage adjusted. Sometimes pads of this kind may be made to serve in the place of splints. In the knee, for example, a bandage, as usu- ally applied, is of very little use; nor is it much better if a horseshoe-shaped cushion is adjusted around the knee-cap. But if this is combined with a firm elastic pad of felt in the popliteal space behind (I have known, when nothing else could be obtained at the moment, a small folded pocket-handkerchief answer admirably), the compression is spread over a larger surface of the joint, better resistance is given for the bandage in front, and an admirable splint is applied to the knee joint, keeping it nearly straight, and possessing the great advantage over an ordinary back splint that it is not so absolutely and uncomfortably rigid. Sometimes it is one's misfortune to meet with a case in which the limb (generally the forearm) seems to have been sprained, as it were, all round, the swelling and pain are so universal. For such as these I have used with success what may be considered a distant imitation of Guerin's treatment of wounds ; that, at least, first gave me the idea. The limb is to be well padded first, according to the anatomy of the part, and lightly bandaged ; then, commencing from the fingers, be- tween which small cushions are placed, it must be wrapped in sheet after sheet of cotton wool until it is three or four times the natural size ; finally, it must be bandaged from below up- ward as firmly as possible. If the cotton wool is sufficiently thick it is impossible to exert too much pressure. It must be admitted that the application is exceedingly hot; but it cer- tainly relieves pain ; and such is the elastic tension of the wool, that the limb, when exposed on the next day, is almost its natural size. The comfort is greatly increased by dusting the limb over first with violet powder. 96 Sprains ; their Consequences and Treatment. Bandages used for sprained joints need not be of any special kind so long- as they lie evenly and smoothly on the limb and do not stretch. India-rubber ones, or those made of woven elastic, are strongly recommended by some; but, it seems to me, without adequate reason. They keep the limb very hot ; the solid ones, at any rate, retain the perspiration so as to be sometimes unpleasant; and it is very difficult to apply them sufficiently firmly without making- them too tight and con- verting them into a species of torture. While the limb is being bandaged the pads may be secured in position by means of common elastic bands passed round the limb, an excellent method suggested by'Dacre Fox. Starch bandages and other fixed appliances, such as gum and chalk, plaster of Paris, or silicate of potash, can only be recommended under special conditions. They are certain to be left on too long, and that is a fatal objection. Bandages, as a rule, should be changed every day. The limb no doubt feels fairly comfortable so long as it is encased and kept motionless. But every day it is growing more and more stiff, and when it is released the least attempt at movement is attended by pain. This is not due to straining or tearing of the union between the ends of the torn ligaments ; no strain falls on it. Ligaments may be tense, but they are not stretched unless movement is carried beyond what is natural, which, under proper manage- ment, never should happen. It cannot, therefore, be due to this. In reality its persistence and severity are . regulated more by the amount and duration of the swelling than by any- thing else. Of course if ligaments have been torn from bones, or muscles have been strained or lacerated, the skin over them is tender when it is pressed upon or tightly stretched, but the pain that is ordinarily felt when a sprained joint is first used is scarcely noticeable if exudation is prevented and passive motion begun early enough. Neither of these conditions is likely to be carried out properly if the limb is encased in a fixed bandage. How long the limb should be bandaged is a question that can hardly be answered until the effects produced in joints by prolonged inaction have been taken into consideration. CHAPTER VIII. TREATMENT. REST. NOTHING is so difficult in the treatment of sprains as the question of rest how long the joint should be kept quiet, and when the patient may use it with safety as he likes. It is the first thing 1 asked, and a definite time is usually wanted at once, utterly regardless of the fact that it is impossible to re- turn more than a general answer in the majority of instances. Each case must be judged on its own merits. On the one hand, if the joint remains long unused, there is the possibility, almost the certainty, of its becoming stiff and crippled, so that it is years before it regains its natural freedom, if it ever does; on the other, there is the dread of exciting inflammation, and the risk of reproducing by some momentary slip the whole of the original mischief. Between these it is necessary to hold a middle course; leaning too much to either side inevitably brings after it delayed convalescence in some form or other and much discredit. There is no doubt that in the majority of cases sprained joints are kept at rest much too long. It is imagined that if anything, it does not matter what, has happened to a joint, it cannot be wrong to rest it, and that no harm can possibly fol- low from its being kept quiet. The dread of inflammation is allowed to overshadow everything else. It is forgotten that the function of a joint is movement; that this is the reason for its existence, and that if from any cause it is kept abso- lutely at rest it loses the power of working, just as an eye ac- customed to long-continued darkness becomes unable to bear the light. It is forgotten that prolonged rest does produce changes, and very definite ones, too, in the structure of joints, even when they are healthy, and that these are tenfold more likely to occur after injury. And so the part is kept perfectly quiet until it becomes stiff and rigid, and every attempt at movement causes pain. 9$ Sprains ; their Conseqicenccs and Treatment. Effects of Prolonged Rest on Healthy Joints. Some of the effects stated to result from this cause are of a very strik- ing 1 character. Duverney and Petit have described cases in which they found the sy no vial sac and the spaces round it enor- mously distended with a serous effusion ; and others in which there were adhesions passing 1 across the interior from one bone to the other, so that the joint was almost crippled. Teissier has given an account of one in which the adhesions were so dense and numerous that the cavity of the joint was entirely oblit- erated, and the bones so tied together that one could not move in the least upon the other. In others he found the synovial sac distended with blood, the lining membrane thickened, and more vascular than natural, and the inner surface coated over with a recent deposit of fibrinous material, which was rapidly being organized into dense unyielding bands. In many the cartilages were swollen and thickened at the margin, softened in the centre, and even eroded on the surface, while the syno- vial fringes were almost uniformly converted into tough fibrous bands that limited the fredom of the joint in all directions. Some doubt, it is true, has been thrown upon his explana- tion, owing to the fact that in all the cases the limb had been severely hurt; and the suggestion has been offered that these changes are really due to inflammation, which spread from the seat of injury to the affected joint; but it is admitted that there is no evidence that anything of the kind had occurred. According to Teissier, unbroken rest can be the only cause; and in this he is strongty supported by Bonnet of Lyons, who came to the same conclusion after a series of experiments ex- pressly bearing on this point. It is admitted that the position in which the limb is retained is of some importance ; that some joints are more liable to be affected in this way than others, those farther from the trunk more frequently than the nearer ones, the fingers, for example, more often than the wrist ; and, further, that the changes are most conspicuous in the aged, or in limbs that have been paralyzed; but the main fact itself, according to them, admits of no dispute. Even supposing the consequences of long inaction are not so extensive as this, they may still be sufficiently serious to lead to grave discomfort and suffering. It is certain that, in old people at any rate, a rest of comparatively short duration is enough to cause great stiffness, especially when the wrist Sprains ; their Consequences and Treatment. 99 and fingers are concerned. These show the effect more rapidy than other joints, possibly because the movements they exe- cute are so numerous and complicated; even in a few days the power of bending- them may be completely lost ; they re- main rigidly extended, and the least attempt at forcing them, no matter how gently it is done, gives rise to severe pain, and meets with a sense of resistance which is not due to muscular contraction. It is often said when this occurs that the patients are gouty or rheumatic, and that the stiffness is due to their diathesis; but there is no evidence of it. It comes on without aching or pain, that is not felt until after manipulation; the skin is not hot: there is no swelling or sign of inflammation; the onset is imperceptible; and the patient is unaware of anything being wrong until the hand is released from confinement and some attempt made to move it. There does not seem any other reason possible but the want of use and the prolonged rest in the straight position. Changes in the Tissues Due to Prolonged Rest. When the time is short these are not very conspicuous. There is less fluid in the joint, and its quality sometimes appears to be altered; it is not so viscid as it ought to be; but it is rare to find anything more. The tissues themselves do not seem to be affected as they are at a later period, and recovery is gen- erally rapid. Afterwards there are other alterations; the loose and delicate connective tissue that fills up all the irregularities and interspaces becomes affected. In some parts it is com- pressed until it becomes dense and hard ; in others it is filled with fluid, and becomes soft and pulpy. Then, as the bones and muscles move, and the pressure shifts from one point to another, the uneven tension causes pain. Instead of the tissues yielding smoothly and evenly, accommodating themselves to each other so that no unfair pressure falls on any part, some are hard and resistant, having completely lost their flexibility ; others are swollen and distended, so that they cannot give way. The effect, if force is used, is much the same as when a ligament or any other band of connective tissue is stretched beyond its natural limit; the part swells up and becomes pain- ful; the temperature rises; and if the attempt is repeated sufficiently often, the changes become more and more marked until they insensibly pass into inflammation. ioo Sprains ; their Consequences and Treatment. In some of the older cases the results are even more serious. The capsule shrinks, and becomes rigid; or, owing- to the re- laxation of the muscles, loses its tone, and is unduly stretched ; the secretion of the sy no vial membrane is completely altered ; the softened parts in the tissues, where there has been no pressure, become, as it were, accustomed to the increase in the size of the space in which they lie, and fill it up entirely ; those, on the other hand, that have been compressed, waste away, so that when the two surfaces of the joint are moved apart there is nothing to fill up the interval, unless the sur- rounding tissues are crushed in by outside pressure. The car- tilages grow thinner and thinner; the ligaments shorten, and hold the bones in rigid apposition; the muscles degenerate, and, accommodating themselves to the fixed length at which they are kept, either contract and become converted into a kind of fibroid tissue, or waste and stretch. The tendons, too, at length become glued to their sheaths, and refuse to move; the skin loses its elasticity and suppleness; there is a blue congested look about it ; it does not move freely or easily over the structures beneath, but seems shrunken on to the bones, as if it were too tight, and all the soft tissue underneath had gone. Even the bones waste, and become so thinned that a comparatively slight degree of violence may cause them to give way. In the Fingers and Ankle. This may happen when the joints are perfectly healthy in all other respects. The fingers have been already mentioned. There is scarcely a fracture of the arm or forearm in which a certain amount of stiffness is not left afterwards. It is not that they have been hurt in any way ; they have merely been kept confined in a straight posi- tion, under pressure, without being allowed to move, and when released they are found to be stiff and rigid. The same thing- occurs in the ankle joint when a patient is confined to bed dur- ing the course of a prolonged or exhausting illness. The foot is kept constantly pressed down by the weight of the bed- clothes into the same straight line as the leg, and at last be- comes fixed in that position ; the muscles on the back of the leg become rigid and shortened ; the ligaments on the front of the joint are elongated and stretched; and when the patient begins to get about he finds that he is unable to place the sole of the foot flat upon the ground, and, not unfrequently, is com- Sprains ; their Consequences and Treatment. 101 peled to undergo a long- and tedious course of treatment before the displacement can be rectified. Not the Eesult of Injury or Inflammation. It is quite true that this condition is more common after injuries than anything- else; but it must be recollected that they are by far the most frequent cause of confinement in one position. It certainly may occur independently of them, as well as of in- flammation; and it cannot be considered a peculiarity of old age, for though it is more often met with in people who have passed middla life, slight degrees of it, sufficiently severe to cause considerable inconvenience, though they yield more readily to treatment, may be found in all periods. Faulty Position. Malgaigne has offered the suggestion that stiffening of joints from rest alone is due not so much to confinement in one position (for then it would be more common even than it is in cases of fracture), but to the fact that the position is unsuitable, and, therefore, hurtful. In his opinion, unbroken rest, combined with extension in the straight line, is the immediate cause. The natural position of repose, in which the ligaments are relaxed, lies between the extremes of flexion and extension; if a joint is kept for any length of time rigidly straight some of the ligaments are loose, others are in a state of constant tension. The former gradually shorten, and be- come rigid and unyielding; the latter stretch, and grow weaker and weaker, or even at last become inflamed, owing to the un- natural condition in which they are maintained. In either case, the suppleness and flexibility are lost, and when an attempt is made to move the joint, pain is caused owing to the fact that the tension falls unfairly on them. It is not unlikely that this is correct in the main, and that if a joint is perfectly healthy there is not much fear of its be- coming stiff, unless the limb is kept in such a position that un- fair traction is maintained continuously on ligaments which are not suited to resist it. The important fact is that it may occur indeed, that in some circumstances it will occur even when a joint is absolutely sound. If it has been sprained, if the ligaments and the capsule are softened by exudation, and by the changes in the circulation that of necessity take place after injuries, continued rest is almost certain to produce it in a very severe form. The length of time need not be great; very few days are sufficient; and the actual alteration in RT/no?5Tc 533JJOO IDrtU.^ - : i1 . 1.OK-VHH 102 Sprains ; their Consequences and Treatment. structure need not be of great extent; a fold of the capsule may be thickened, or some of the synovial fringes matted to- gether, or there may be merely some induration in the soft tissues, or filling up of the bursal spaces on the outside of the joint, a state of things that may be produced in a few days at the most; it is quite enough to prevent the free action of the joint and to give rise to severe pain if the attempt is carried too far. In the majority of instances joints that continue stiff and crippled for such a length of time after being sprained show nothing more than this, and it does not appear to be much. There is no heat or redness of skin; the swelling is only such as would be accounted for by the extravasation of blood at the time, and the amount of exudation that is needed for repair afterward; there is none of that throbbing, burning pain which can rarely be mistaken; and there is no sign of inflam- mation. The reason that makes it so serious is, that when once this condition is set up, unless proper steps are taken to prevent it, there is a constant tendency for it to grow worse and worse. The adhesions and contractions that develop dur- ing prolonged immobility cause the softer and more delicate structures to be strained and bruised whenever an attempt at movement is made. Probably, if they are forced to give way once for all, the good that is done far exceeds the harm ; but this rarely happens. Much more often either the sufferer does not move the joint at all, so that it is kept rigid longer still, or, if he has sufficient fortitude to persevere, makes matters worse by half measures. The shortened structures are merely stretched and strained, the part becomes swollen again, a fresh amount of exudation is thrown out, the adhesions grow thicker and stronger, and the joint is doomed to a further course of rest under the impression that it is inflamed. Movement and Inflammation. On the other hand it is urged, even by those who admit that inflammation is not an absolutely necessary consequence, that it is almost certain to be produced if the part is moved too freely or is used too soon. They agree that, unless there are other causes at work, sprains are not more likely to set up an attack of inflammation than simple fracture or any other form of subcutaneous injury; but they insist that it is absolutely necessary to keep the part at rest for fear of its setting in. It seems to me, however, that in Sprains ; their Consequences and Treatment. 103 laying- down a rule of this kind it is advisable to be more pre- cise with regard to the extent and character of the movements executed, and the object with which they are performed. The danger of inflammation does not arise from slowly and care- fully moving an injured joint once or twice a day; the liability to its occurrence is not increased in the least by this. An attack may be brought on by some peculiarity of constitution, such as gout or rheumatism, or by some morbid condition of the blood, inherited or accidental ; or it may be caused by ten- sion if blood or any other fluid is allowed to collect unchecked in the synovial spaces or the tissues round ; but it is scarcely possible to imagine that, once or twice in the course of a day, slowly and firmly straightening out a joint that has been sprained could produce any such result. It is not intended for a moment that anj'one should be allowed to do what he pleases with his limb. There is a popu- lar idea that injuries of this kind can be walked off, that only provided the joint is not allowed to rest for some considerable time no ill result will follow; and there are always to be found people ready to declare that they themselves have done it time after time without hurt of any kind, and that they have re- covered more quickly in consequence. Sprains that admit of being cured in this way can clearly be only of the very slightest description; for such as these it may answer well enough, but it would scarcely be advisable to try it where the tissues have been seriously injured, or where the swelling and extravasa- tion are of any extent. It is impossible to imagine that the repair of a ligament that has been torn in two or wrenched from' its point of attachment to the bone can be assisted by such a proceeding. It may be of service where the strain has fallen on the muscles only and has not been sufficiently severe to tear any of their fibres, or where the effusion is limited to some of the muscular interspaces outside the joint; in others it is- a method of cure which is only too likely to end in disaster. Passive Movement. It by no means follows, however, that the extreme opposite course should be adopted and the limb maintained in a state of absolute immobility. It is quite pos- sible to move a sprained joint sufficiently to prevent the oc- currence of stiffness or the formation of adhesions without causing the least pain or suspicion of inflammation. The first thing is to check the swelling of the part; if this can be pre- IO4 Sprains ; their Consequences and Treatment. vented passive movement may be carried out with no more than a sense of inconvenience. The pain, throbbing, and risk of inflammation are due to the distention of the joint and tissues round, and to the continued traction exerted on the nerves. If this is stopped at the first the joint may be quietly, but firmly, flexed and extended without causing anything deserving the name of suffering, and without any fear of reproducing the original accident. Movement undertaken with this object must be passive, not carried out by the patient. Active movements are effected by the contraction of the muscles, acting in their ordinary course, and are executed for some purpose, or in opposition to some resisting power; passive ones, on the other hand, are carried out by some other force, as when one person bends and extends the limbs of another who exerts no strength himself; or when the finger joints of one hand are worked by means of the other. The bones are moved one on the other; the tendons play backward and forward in their sheaths ; the folds of the synovial membrane and of the capsule are alternately straightened out and compressed ; the pressure points in the tissues are shifted as they are in normal action ; and, what is especially important for maintaining their vigor, a certain amount of traction is put upon the muscles and nerves; but no work is done. The joints are treated as complicated pieces of machinery, each part of which is moved by some external force, in a direction, and with a range, that can be limited with the greatest nicety. If one of the restraining ligaments is torn or hurt, no stress need fall on it ; if the soft tissues on one side are bruised, they need not be pressed upon; and if a muscle has been ruptured, its ends are not more widely sepa- rated from each other. Everything can be regulated with the greatest accuracy. Time for Movement. The sooner this is begun the better. It is very rare for the tissues on both sides of a joint to suffer to the same extent. Those on one aspect may be torn, those on the other bruised, from the way in which they are crushed together when it is twisted; but the latter recover long before the former, and are capable of carrying out all their ordinary work at a time when a comparatively slight strain would tear the others in two again. As a rule, passive movement may be commenced from the second day with the certainty of pre- Sprains ; their Consequences and Treatment. 105 venting- adhesions, and without the least fear; it can be regu- lated much too well to allow any tension to fall on the injured part. This answers especially well when the ligaments have suf- fered most. As a rule, these structures cannot stretch ; their function is solely to prevent movement being" excessive or pass- ing some definite limit. So long" as the range of action is kept within its normal bounds no strain falls on them; they are merely straightened out or unfolded, as it were. When a joint is sprained the movement is carried beyond this, and the liga- ments, unless they are strong- enoug-h to resist the momentum, yield and give way; but even after this has happened, if the part is prevented from swelling, it may be made to execute all ordinary movements without fear of hurt, provided it is handled carefully by one who knows how much may be done. It need not be said that hap-hazard or careless movements must be absolutely forbidden. The most accurate diagnosis is necessary to make certain what structures have suffered and what have not; and there must be a thorough and exact acquaintance with the action of the joint, so that the right kind and right degree of movement may be selected; but pro- vided this is done there is no reason why the joint should not be worked in this way from the very first. If it is carried out thoroughly adhesions cannot form. If a tendon has been dislocated, and the sheath of fibrous tissue which maintains it in its groove torn open, or if one of the cartilaginous discs which exist in some joints, such as the knee, has been displaced, the part may be exercised without fear of reproducing the dislocation or of delaying the union of torn fibres. In the ankle, for example, it is not uncommon for the tendons on the outer side to be displaced forward on to the bone. They are, ordinarily speaking, held firmly down by a fibrous sheath thrown over them, and lined with a delicate synovial membrane; sometimes this is torn, and the tendon escapes from its bed. When this has once taken place a single incautious movement on the part of the patient, before the sheath has had time to repair itself, may tear it open again and reproduce the dislocation; and if this happens more than once it is not improbable that repair never will be carried out ; that the sheath will remain loose and yielding, allowing the tendons to slip backward and forward with the slightest io6 Sprains ; their Consequences and Treatment. twist until the use of the corresponding 1 muscles is practically lost. But if passive motion is employed systematically and carefully by some other person, who knows what the injury is, and how best its ill-effects may be avoided, the joint may be exercised thoroughly, flexed and extended as far as is desirable, and the nutrition of the muscles permanently maintained with- out the least fear of this untoward complication. Even in the most severe sprains, when the staining- due to the extravasated blood reaches, as it often does, nearly up to the knee-joint, it is advisable to begin on the second, or, at the very latest, on the third day. All that is necessary is that the whole of the swelling- should have been dispersed by care- ful bandaging-, or by other means. The foot is then to be re- leased from all constraint, the skin and the subcutaneous tis- sues thoroughly kneaded, and the joint quietly, but firmly, flexed and extended several times as far as it is ordinarily in walking. This should be repeated every day until recovery is perfect, the limb in the meantime being as carefully and methodically bandaged as it was at first. At first, no doubt, there is considerable apprehension on the part of the patient, and probably the muscles are uncon- sciously kept rigid and resisting; but this is easily overcome by kneading and steady, gentle pressure. Gradually, as the fear of being hurt diminishes, the movements become more and more free until all that is wished can be executed without dis- tress. Pain ought scarcety to be felt. Of course, if a ligament has been torn off the bone, and direct pressure is exerted on the spot, it is felt acutely; but these are the places that should be carefully avoided, especially at first. After a little manip- ulation the tenderness generally diminishes considerably. If the swelling has been thoroughly dispersed, so that there is no tension on any part of the capsule or the tissues round, and if care is taken not to move the joint, so far as to put undue strain on a ligament that has been stretched or torn, the nerves are not dragged upon or compressed, and the move- ment is practically painless. The ankle joint, owing to the plan of its construction, is peculiarly well suited to this method of treatment. Sprains are nearly always caused by the foot being suddenly twisted to one side or the other, so that the greatest strain falls on ligaments, which in all ordinary movements, are only moder- Sprains ; their Consequences and Treatment. 107 ately tight. The slightest attempt at bending the foot later- ally, in the direction of the original twist, causes the most in- tense pain, and all the muscles round become involuntarily rigid. All ordinary movements, on the other hand, are allowed to take place from the first, without the least resistance, after the natural feeling of apprehension has been overcome. I have repeatedly seen the most severe cases treated in this way recover so completely in the course of a few days, that, unless there was an exceptional amount of walking to be done, the patient could follow his ordinary occupation without danger and without pain. Of course, if a ligament is torn across, a certain amount of time is required before it can unite, and still more before it can be firm; but the position in which the structures are placed by this plan is unquestionably the most favorable for speedy recovery. The ends lie in close apposi- tion to each other; no external force is allowed to separate them, and, what is much more important, the synovial cavity of the joint is not allowed to remain distended with fluid, keep- ing the torn surfaces continually apart. If this is carried out fairly and consistently from the commencement, it is impossi- ble for the joint to become stiff. Adhesions between contiguous surfaces are effectually prevented by the passive motion. The free manipulation renders any rigidity or contraction of the capsule impossible. Unless there is some other predisposing in- fluence, inflammation is equally out of the question. There is no tension to excite it, and, if the compression is properly carried out, there can be no dilatation of the blood-vessels to pave the way for it; nor need there be any fear that afterward there will be that peculiar sense of weakness and insecurity which is so common as a consequence of sprains. In by far the ma- jority of instances this is due to distention of the capsule or yielding of the ligaments ; or, when this does not occur, to the fact that the muscles, from being so long unused, have become stiff or rigid, and do not respond as actively or as vigorously as they ought. OHAPTEE IX. FORCIBLE MANIPULATION. FEW modes of treatment have had a more curious history than forcible manipulation as applied to stiff joints. Often, for years together, in the greatest disfavor, owing-, it must be admitted, to indiscriminate application, and almost discarded, it has always managed to retain a foothold in some part or other; and every now and then, when its mishaps have been forgotten, has sprung up again into notoriety, under, perhaps, some change of name. Very few minor operations are capa- ble of giving such instantaneous and striking relief. It often happens that, as a result of some simple manipulation, a joint that has been crippled and the seat of pain for weeks and weeks is suddenly and completely released ; but, at the same time, it must be remembered that, unless proper care is taken in the selection of cases, very few operations can do more harm, and also that it is not always easy to lay down rules by which the choice is to be guided. Adhesions must be Divided or Torn. If a joint is stiff and rigid from shortening in the fibrous tissue round it, there is only one thing to be done, only one plan of treatment that holds out a reasonable prospect of success: the contracted tissue must be either divided or stretched. Nothing else is of any avail. Baths, whether hot, or cold, or douche ; galvanism, massage, friction, counter-irritation, blistering, and the num- berless other remedies so often employed, are of little or no service. It is true that the circulation and nutrition of the part improve under their use ; the muscles recover their tone and firmness; the skin becomes more healthy in appearance, and the general aspect of the joint is altogether different; but if, when the muscles were relaxed, the movements were stiff and constrained, they will continue in this condition, no matter how energetically these methods are carried out. They are Sprains : their Consequences and Treatment. 109 necessary as accessories; in fact, they are almost indispensa- ble as a means for educating- the muscles and nerves, so that they can exert their power again as soon as freedom of move- ment has become possible; but of themselves they can do little or nothing- toward g-etting rid of the stiffness when there is the least degree of change in the fibrous tissue. This has been learnt by dint of experience of the roughest kind. The strange idea that sprains are nearly always fol- lowed by inflammation (though it is admitted that it rarely results from any other form of subcutaneous injury), and the dread of causing a fresh outbreak by rough handling, have, to a great extent, deterred those who felt the responsibility from adopting more active measures. At least, this seems to be the most reasonable explanation of the fact that, at the present day, though means for making an accurate diagnosis are so much better than they were, and though it is so easy to avoid the infliction of pain, so little is accomplished by this method, and so many people are content to get about, as best they can, with joints which, at the most, have only partially recovered. Even then it is not easy to understand why there should be such objection. Supposing for an instant that inflammation were a much more common consequence of sprains than it really is, it is very unlikely that an attack would be caused by moving a stiffened joint within its natural limits, especially when every precaution is being taken to prevent its occur- rence. The popular treatment is absolute rest; but though this, as already mentioned, is necessary under certain condi- tions, it must always be remembered that a joint can never become healthy so long as it remains unused. Division. Of the two methods I have mentioned, the first, division, is very rarely required in the case of simple sprains. Sometimes, it is true, the muscles on one side of a limb become so hard and rigid from long disuse that they refuse to yield to any reasonable amount of force, and then something of the kind must be done; but this is not common. It may occur in the ankle, when a patient has been for some time confined to bed, with the w r eight of the clothes resting on the front of the foot, constantly pressing it into the same straight line with the leg. When this happens, the muscles at the back of the calf grow more and more rigid, until, if proper steps are not taken to prevent it, they become permanently contracted. If an no Sprains; their Consequences and Treatment. attempt is made to move the joint against them, it feels as if two bony surfaces were being driven against each other; it does not yield in the least; the foot is hopelessly fixed, and there is no alternative but to divide the tendon. Structures that require division are rarely situated close to a joint. As a rule, they have little or nothing to do with its synovial lining, or even with the loose fibrous tissue outside the capsule. For the most part they are attached to distant points, and are either thickened portions of the fascia, which have undergone passive contraction, or tendons of muscles shortened from disuse. These have to be divided before any thing further can be done; but though this is not unusual after a joint has been inflamed, it is rare to find such extensive changes after mere sprains. In any case it is necessary to examine the limb thoroughly beforehand while the patient is under an anaesthetic. It very commonly happens that what is apparently absolute rigidity disappears at once when the muscles are relaxed. When division is required it must be carried out in accord- ance with the ordinary rules of tenotomy. A preliminary course of kneading is frequently of great benefit; it loosens the subcutaneous tissue, and makes the skin more supple and yielding; but care must be taken to give the part a complete rest for at least two days before. The fewer the number of punctures, and the smaller the size, the better, so long as it is done thoroughly. Very often, after beginning, it is found that, independently of the superficial bands, there are deeper ones beneath, the presence of which could not be ascertained before; whenever it is safe, they must be treated in the same manner. In all cases the punctures must be allowed to heal before the least degree of extension or manipulation is attempted, for fear of tearing the skin, as this is often exceedingly thin over such parts. In general, four or five days are sufficient. Then, if firm pressure is made with the thumb over the point of sec- tion, while the part is being manipulated, the newly-formed fibrous tissue between the deeper structures is easily made to yield without fear of injury to the rest. Failure of union, when a tendon or a band of fascia is divided in only one place, is quite exceptional. Manipulation. Manipulation is much more useful than division; it can be employed for such a variety of purposes. In Sprains ; tJieir Consequences and Treatment . 1 1 1 the early stages it prevents the occurrence of stiffness or the formation of adhesions. Later, when the swelling- and heat have disappeared, it is no less successful in restoring- freedom and ease of movement, and afterward, when all mechanical obstructions have been cleared away by its use, it is one of the most effectual methods known for bringing back the circula- tion and nutrition of the part, and giving again to the muscles and nerves the energy which has so long been wanting. When the object is to set free a stiffened joint, it may be applied in one of two ways. The first aims at breaking down all obstacles at once by a few vigorous but well-directed move- ments; the second merely attempts to stretch the contracted tissues, little by little each day until they cease to act any longer as an obstruction. The principle is quite distinct. Each plan has its own advocates, but it is especially urged against the former that it is a rough and bap-hazard method of pro- ceeding, likely to excite inflammation, and always liable to do more harm than good. Rapid. In certain cases no doubt this may occur. There are plenty of instances on record in which limbs, and even lives, have been lost by reckless manipulation. But this is entirely due to the fact that the cases were unsuitable, and that sufficient precautions were not taken. 1 When carried out properly and scientifically, rapid manipulation is not only more efficacious, but is more free from risk than the slow and tedious process of stretching the opposing tissues little by little. Strange as it may seem at first sight, there is scarcely any- thing in the proceeding itself that can cause inflammation. Tearing across bands of fibrous tissue is no more likely to pro- duce it than breaking a bone or dividing a tendon. There is little that is different and nothing that is exceptional in the nature of the injury. A certain amount of blood is extra va- 1 The following instances in which manipulation was either at- tempted or proposed are mentioned by the author of one of the most recent and complete works on Diseases of the Joints (Howard Marsh) as having occurred under his own observation : Malignant tumor of the thigh ; malignant tumor of the shoulder ; disease of the spine ; three cases of scrofulous disease of the knee-joint ; haemorrhoids ; and a case in which, after the hip- joint had already been excised, it was gravely declared that the bone was out, and must be replaced. The list could easily be extended. 1 1 2 Sprains ; their Consequences and Treatment. sated ; the vessels dilate ; more lymph is poured out to repair the damage; but unless there is some grave constitutional affection present in addition, or it is followed up by serious maltreatment, this is no more likely to excite inflammation than a single bruise or subcutaneous laceration in any other part of the body. The capsule of a joint is always extensively torn in dislocations, but they are never followed by inflamma- tion unless some similar cause is present, and it is difficult to understand why it should be so much feared when the injury is so much less. Slow and Gradual. Repeated straining 1 , on the other hand, constantly attempting- to stretch the contracted tissues, is one of the surest ways of exciting- it. It does not matter how carefully it is managed. Each time a stiffened joint is gently worked the fibrous bands that check its movements are stretched, and very likely slightly torn; each time, in short, the tissues are sprained again, so that they become more and more tender and swollen. One of two things then must hap- pen. Either the interval before the next attempt is not long enough for them to recover, the heat and swelling never have time to subside, and the joint becomes inflamed, though it does not regain its freedom, or for fear of such an untoward occur- rence manipulation is abandoned for a time, thorough rest en- joined, and all the improvement lost; the bands regain their strength, and the stiffness becomes worse than it was before. One method aims at restoring perfect freedom at once with a single risk; in the other the danger is incurred again and again, each occasion being worse than the one that preceded it, without the chance of recovery being nearly so good Accidental Bone-setting. I must not be understood to advocate indiscriminate employment of forcible movement in all cases alike; it is just this which has brought it into such disrepute, and caused such an amount of opposition; only where other things are equal, adhesions in connection with sprained joints are far better broken across, once for all, than repeatedly strained and stretched. There is no difficulty in supplying examples in proof of this. One I have mentioned already while describing the changes that occur in the tissues round a joint after injury, and it is by no means a solitary, or even an unusual, case. A very similar one was narrated to me a short time since by another patient. According to his Sprains; tJieir Consequences and Treatment. 113 own account, he had fallen clown, with his arm outstretched, some time before, and (as was very probable) had dislocated his shoulder. It was reduced by a surgeon, but, for fear of reproducing the dislocation, the arm was kept bandaged close to the side for nearly six weeks. At the end of that time he could scarcely move it, and was almost convinced from the stiffness of the joint that the dislocation had never been re- duced at all. It got better, however, by slow degrees, until he was able to move his arm in all directions, except upward and outward; the least attempt at this was stopped at once by a sharp stab of pain on the inner and under side of the joint. This continued until one day, about four months after the original accident, falling down again in much the same way, he felt a sudden snap, which hurt him intensely for the moment. Probably this was due to the rupture of a band, or of some contracted portion of the capsular tissue; at any rate, he found to his astonishment that his arm was from that moment practically free. Nothing afterward could turn him from the belief that the same kind of fall had both dislocated and reduced his shoulder joint. It was certainly wonderful that he did not dislocate it a second time. In the ankle, when it is left stiff and painful after a sprain or fracture, manipulation carried out in this way is always worth trying. The particular kind of case in which it is likely to be successful can often be recognized at once. The skin over it is red and shining, as if it were stretched too tight; the color disappears readily when it is pressed upon, but is very slow in returning; firm pressure often causes it to pit, especially where there is a large amount of subcutaneous tis- sue; at the same time it feels cold to the touch. There is no displacement or dislocation; the outline of the bones is quite natural, though all the depressions are partly filled up, and the prominences rounded off; and the tendons can, generally speaking, be traced to their grooves. The position, however, is awkward, so that when standing upright the sole cannot rest flat upon the ground; movement is limited, and exceed- ingly painful at certain spots; and there is constant aching, especially at night or after any exertion. In several cases such as this, by putting the patient under an anaesthetic and working the joint thoroughly, I have succeeded in restoring perfect freedom of movement, sometimes at the first attempt. 114 Sprains ; their Consequences and Treatment. It is essential to recollect in dealing with this part that though the original injury may have appeared to be confined to the ankle, the other joints of the foot rarely escape entirely; and that even if they are so fortunate, they have been kept con- tinuously at rest as much as the ankle, and have undergone similar changes. For want of this precaution, I have seen more than one case fail at the first, and only succeed when the manipulation was extended to the others too. Sprains of the wrist, again, often leave the fingers stiff and rigid for weeks, long after all heat and swelling have disap- peared. In a case recently under my care the patient had fallen, about three weeks before, down a flight of steps, bend- ing his right wrist-joint beneath him. According to his own account, he lay for some time (how long he scarcely knew) unconscious; and on coming round found that his arm was in- tensely painful, and that there was an enormous amount of swelling over the back of the hand and wrist, extending some distance along the forearm. This was reduced by careful bandaging, so that when I saw him it had almost disappeared, though there was evidence in the staining of the skin by the elbow how severe the injury had been. The hand was quite cool and painless so long as it was left alone, but he had not the least power over his fingers; they lay nearly straight, not apparently hurt, slightly swollen it is true, so that the shape of the joints was too rounded and uniform, but with nothing else about them to show that they had been injured. With the aid of the other hand he could almost bend them down into the palm, though it gave him a considerable amount of pain; but as soon as they were released they sprang back again almost mechanically. He was directed to have the part thoroughly kneaded and steamed for a few days; and at the end of the week was placed under an anaesthetic, and every joint in the fingers and wrist systematically worked through its full range. The next day the hand felt very sore, and was slight- ly more swollen, but this soon disappeared under massage. Movement was slow, and executed with great deliberation, but the range was much wider, and he was encouraged to use it freely. Two days after full power had nearly returned, and he was able to resume his work. Where Rapid Manipulation is Suitable. The joints in which this plan of treatment is most successful are those which Sprains ; their Consequences and Treatment. 1 1 5 are cold, but not much wasted, where the adhesions are still recent, and especially where, from the pain and tenderness be- ing 1 constant at one spot, there is some probability of the con- tracted tissues being- limited in extent. Hinge joints, in which the movements are, comparatively speaking, simple, and take place only in one plane, can be treated much more easily than ball and socket ones, or those in which the variety of move- ments is more extensive. An anaesthetic should always be given unless there is some special reason against it. Not only does it render the opera- tion painless, but by insuring- that the muscles are relaxed, it enables the maximum result to be obtained with the least degree of violence. In many cases, indeed, it is necessary, in order to make the diagnosis exact; so long as the muscles are contracted, it is often impossible to give an opinion either as to the strength or the extent of the adhesions. The ob- struction itself may be of the slightest description, and the limb so rigid as apparently to have lost the joint altogether. No ordinary degree of force may produce the least effect; but as soon as the contraction of the muscles is done away with, the mere weight of the part is sufficient to separate the adher- ent surfaces, and restore perfect freedom. Preparation. When some time has escaped since the acci- dent, and the circulation is feeble, or when the skin and the subcutaneous tissues appear thin and shrunken, it is not ad- visable to attempt this without a certain degree of prepara- tion. The joint should be well steamed, or douched with water from a jet of moderate diameter, commencing with it fairly warm, and finishing up with cold; or it should be thoroughly kneaded every day, for a week or a fortnight, to loosen the skin and bring back the circulation. No pains should be spared to insure this. Great stress is laid by some on the use of oil, which is to be well rubbed in; and certain kinds are much more highly recommended than others; but in all probability the beneficial effect is entirely due to the friction. A small quantity of oily matter is no doubt absorbed, but it is impos- sible to imagine that its action under these conditions is me- chanical, as this would imply. The operation itself is not so simple as might be imagined. It is true that occasionally the most extraordinary recoveries are effected by falls or other accidents ; but it must always n6 Sprains; their Consequences and Treatment. be remembered that these are only heard of when they are successful ; and that, very probably, they are quite the excep- tion. In the majority of cases failure is much more likely, un- less a definite and well-ordered scheme is followed out. Method. The chance of success is greatest when the ob- struction can be accurately localized. No pains should be spared to effect this. The joint must be thoroughly examined in every position it can be made to assume; any spot that is tender must be marked beforehand; the movements that cause an increase in the pain must be noted, both as regards direction and extent, as well as the least irregularity or un- even ness as one part glides over another. It is entirely owing to their power of appreciating minutiae of this description that some persons have acquired such a reputation for the treat- ment of these cases. The patient must be placed. so that the portion of the limb between the affected joint and the trunk can be fixed securely by an assistant while the lower part can be freely moved by the operator. In the case of the larger joints, one hand should grasp the limb immediately below, so that the thumb may press firmly on any spot that is tender; the other must be sufficiently far off to secure a proper amount of leverage. All rapid movements should, so far as possible, be in the direction of flexion, combining with it abduction, adduction, or rotation, according to the case, so that the tension may be directed to the required spot. To carry this out effectually two things are needed beyond all others. The one is a sense of touch so delicate that it can appreciate the least resistance or irregularity of movement ; the other an accurate knowledge, not merely of the ordinary anatomy of the part, but of the different degrees of tension that fall on the ligaments in every position of the limb. Each joint requires a different kind of manipulation accord- ing to its construction. In the case of the shoulder, for ex- ample, the elbow must be bent so that the forearm may be used as a lever, and the arm rotated first to one side then to the other, bringing it across the chest and carrying it round behind the back before any attempt is made to raise it from the side. Bringing it up at once would very likely dislocate the joint. For the knee Hood recommends the foot of the affected limb to be held by the operator between his thighs, Sprains; their Consequences and Treatment. 117 so that when flexion is accomplished by the hand it may serve as a lever for rotation. This, however, can be effected by the hands alone if the muscles have been relaxed by an anaesthetic. The smaller hinge joints can be managed even more easily, flexion being- combined with lateral or rotatory movements so far as the shape of the bone will allow. There should be no jerking. The movements must be vig- orous and forcible, but perfectly smooth ; and they must be carried out thoroughly, the joint being moved to its full ex- tent in all directions that are natural to it. Each kind of action should be combined successively with the rest, one by one, so that the tension may fall in turn upon all the different parts of the capsule. Movements which are especially restricted or painful of course require most attention, but the others, though they may not be affected to the same extent, are not to be neglected. It sometimes happens if these are dealt with first that a con- siderable proportion of the main obstruction is cleared away, as it were, by side attacks, so that when its turn comes it yields more readily than it otherwise would. Recent slight adhesions give way at once without a sound, though the sensation is generally conveyed to the hand. When they are older the noise may be as loud and clear as when a bone is broken. Probably in many cases this is due not so much to the actual tearing of adhesions as to the sudden sep- aration of two synovial surfaces that fit accurately into each other. The noise that can be produced in this way, especially if a table or other structure is made use of as a sounding board, is well known. The after treatment of these cases should be in all respects the same as that of a recent sprain, only if passive motion at an early date is advisable to prevent the occurrence of stiff- ness in the one, it is absolutely necessary in the other. The joint must be worked systematically every day from the first. If the adhesions have been thoroughly broken across, and if swelling is prevented by compression, it is almost painless. In exceptional cases it may be necessary to administer an anaes- thetic the first few times. Manipulation as an Exercise. This, however, is not the only use for forcible manipulation. Even when all adhesions have been broken down and the action of the joint thoroughly n8 Sprains; their Consequences and Treatment. re-established, voluntary power is often slow in returning 1 . The joint itself may move with perfect freedom, but the mus- cles, and even the nerves, seem to have lost their power. It is so long since they have done any work that they have be- come unable to do any. They are wasted and shrunken in size; the circulation in them is defective; possibly their struct- ure, even, has undergone some alteration. Whatever it may be there is no question that, when a case has lasted any time, their strength and vigor become seriously impaired. The joint cannot be considered cured merely because the mechan- ical obstacles to its action have been removed; something more than this is required. Recovery is not complete until the natural condition is restored, and the joint is able to under- take active work again. Exercise, of course, is the most effectual remedy for this. When it can be carried out the cure is rapid and certain, but in many cases it seems impossible. Sometimes there appears to be an actual inability to make use of the muscles, as if the power of the will was unable to reach them. Sometimes the sense of insecurity is so great that the patient cannot be per- suaded to place sufficient trust in them. Whatever the cause may be, forcible manipulation is of the greatest service in these cases, especially if it is helped by massage and galvan- ism. The way in which it is used is, of course, very different to that already described, and the object is different; in the one its purpose is to tear across adhesions, in the other to rouse latent muscular activity, but if used systematically, success, though, perhaps, not quite so conspicuous, is equally sure. Elaborate accounts have been written from time to time of what has been called the movement cure, and many varieties of manipulation have been described in connection with it, but, so far, at least, as the treatment of sprains is concerned, it does not seem clear that they possess any great advantage one over the other. The principle in them all alike is to exer- cise the muscles according to their strength, to stretch them out, and manipulate them without fatigue. In most cases the greatest amount of benefit appears to be obtained by making use of the different plans successively, beginning with that which calls for the least effort on the part of the patient. Simple extension, gradually straightening out the muscles, one after the other, with some degree of force, until a distinct Sprains; their Consequences and Treatment. 119 sensation of resistance is experienced, is especially useful in the earlier stages, immediately after the adhesions have been broken down. Sometimes the muscles are irritable, and in- clined to painful spasmodic contraction ; or hard knots form in their substance, possibly due to rupture of a few of the fibres; or a certain degree of soreness and tenderness of skin makes itself felt over them. Whatever may underlie them, these conditions are often relieved by slowly but firmly extending-, one after the other, the various groups of muscles that lie round the joint, and applying firm and even pressure. What are known as resistive movements are of much wider application. In these the patient either carries out a definite course of action against the resistance of the operator, who is able to select any particular group of muscles, and regulate exactly the amount of work, or the latter makes use of his strength to oppose some voluntary action on the part of the patient, compelling him to give way. The former of these methods is by far the most useful of the two. The secret is to keep the opposing force well within the limits of the patient's strength, making use alternately of flexion or extension, or of rotation inward or outward, as the case may be. Exercise of this description certainly possesses wonderful influence on the nutrition and activity of the tissues, not the muscles only; and with a reasonable amount of care it may be kept up for a considerable time each day without overfatigue. The other plan tires out the muscles at once, and is too exhausting to deserve strong recommendation. In some cases it is possible to substitute for the hand of the operator mechanical contrivances, arrangements of wheels and levers adjusted to resist any individual movement that may be wished, and capable of being graduated exactly by the patient to suit his own strength. The action, however, is not quite the same. The resistance of a spring or an elastic band cannot be graduated like that of human muscles, guided by an experience of what is required; and unless very carefully superintended the progress of cases treated in this fashion is apt to be very uneven and irregular. CHAPTER X. MASSAGE. MASSAGE, again, which is a most valuable remedy in the treatment of sprained joints, has a history as strange as that of forcible manipulation. It has never been altogether for- gotten; some people have always practiced it, more or less carefully, and with a varying degree of knowledge and skill; but at certain times, and in certain countries, it seems to have acquired an extraordinary reputation, and then, again, almost capriciously to have been as strongly condemned. Possibly fashion may account for it in certain measure, for this exerts an influence in the use of remedies just as it does over every- thing else; but something, at least, must be attributed to the indiscriminate and unscientific manner of its application by unskilled persons in all cases alike, whether they could or could not be benefited by it. Like many other things it has been destroyed by its own popularity. It is certainly not a novelty; in most countries there has been handed down by tradition from unknown ages a custom of treating injuries of joints and muscles by friction or manip- ulation, and in some places this has been considered a special prerogative of certain families or individuals, who, by dint of long practice and a certain delicacy of touch (perhaps inher- ited), have attained no inconsiderable degree of skill. The modern plan is simply the scientific outcome of this ; the work- ing has been studied more accurately ; its action on the tissues better considered ; and certain rules laid down for guidance in the selection of cases. At one time, for example, Beveridge's rubbers were well known in Edinburgh, and the success that attended their treat- ment (which was carried out very thoroughly and method- ically) had a marked influence on the practice of the Continent. Then the process was almost forgotten, or, at any rate, was Sprains ; their Consequences and Treatment. 121 rarely employed, except in country districts, where rubbing 1 is often used, in a rough sort of way, without skill of any kind other than that derived from custom. Lately, again, owing in great measure to the exertions of Dacre Fox, in England, and Graham, Norstrom, Metzger, and others, abroad, it has been placed on a scientific basis, and received once more into favor. Even at the present day, however, there is too great a tendency to consider it a quack remedy, and to hand it over to persons whose chief recommendation is that they act as untiring rubbing machines, without following any definite rules or guidance. It is often said against it that those who take it up abandon it again as soon as they have had sufficient experience of its results; they find, so it is alleged, that not only does it require a large amount of patience on the part of the sufferer, as well as the operator, but that it is only beneficial to those who would recover as soon without it, and that in some cases it is actually injurious. As a rule, and so far as sprains at any rate are concerned, this arises from the inability to distinguish massage from mere unskilled rubbing. In reality there is nearly as great a difference between them as there is between painting the wall of a house and the work of a skilled artist. The one requires a certain amount of muscular strength and manual dexterity, the other only comes to those who are by nature fitted for it, as a result of teaching and experience. It may or may not be true that it requires two years, as Dr. Murrell states, to learn the process ; that depends on the per- son and on the previous training; certainly many do not acquire the art even in that time. As a general application massage is very widely used. There are many descriptions copied from travelers' works of its employment in one form or another among most of the races of mankind. It was largely practiced by the ancients; the Turks and Africans at the present day make use of it; even among the Siberians and Laplanders it may be found in a form modified by the exigencies of climate ; while the " lomi- lomi" of the Sandwich Islanders is spoken of in terms of en- thusiasm by nearly every one who has written of them for its power of relieving the stiffness and soreness of excessive ex- ertion, and procuring rest and sleep. The effect is described as most luxurious; the process is neither kneading, squeezing, 122 Sprains ; their Consequences and Treatment. nor rubbing, but now like one, now like the other, each muscle is manipulated in its turn, beginning with the head and work- ing down slowly over the whole body, until in half-an-hour the weariness has quite disappeared and given place to a most refreshing sense of ease and comfort. Like many other words that have crept into science from popular usage, massage has scarcely yet acquired a precise or definite meaning. It has been used for every kind of manipu- lation, whether applied to joints alone or to the whole surface of the body, with the hands only, or with the assistance of in- struments. All varieties of friction, pressure, kneading, per- cussion, and even passive motion, have been included in it at one time or another; and the description of the manner in which it is carried out, and the rules by which suitable cases are selected, are proportionately vague and uncertain. For all practical purposes, so far, at least, as concerns the treatment of injured joints and muscles, the various processes that have been enumerated may be grouped under the three heads of friction, percussion, and kneading. Passive motion differs to such an extent in its object and method of applica- tion that it seems unwise to include it. Friction. Of these friction is by far the most simple, and the easiest and least fatiguing to carry out; but its power is very limited, and it has scarcely any direct influence, except on the most superficial structures. It consists merely in a succession of strokings with the hand (using as much of the surface as possible, and fitting it into all the inequalities) from the extremities toward the trunk, commencing lightly at first, and gradually increasing in strength as the part becomes ac- customed to it. The knuckles even may be used where the tissues are very deep-seated, or unusually firm. The skin soon becomes red and warm ; more blood flows through it, the tem- perature rises, and, after a few days' treatment, a distinct change may be noticed in the nutrition of the part. Instead of being hard and unyielding, tied down, as it were, to the subjacent tissues, the skin becomes soft and supple, the natural appearance returns, the folds become visible again, and the superficial tissues begin to regain their firmness and elasticity. Besides this, however, friction exerts considerable influence on the nerves distributed to the skin, and indirectly through them on internal organs, especially on other parts of the Sprains ; their Consequences and Treatment. 123 nervous system. The medium through which this takes place is not accurately known. It is possibly the result of the in- creased activity of the circulation, but more probably it is due to the peculiar sympathy existing- between different parts of the nervous system, by virtue of which one cannot be stimu- lated or excited without influencing 1 the rest. However this may be, of the fact itself there can be no doubt; friction, es- pecially along the back, is often of the greatest service in re- lieving irritability or sleeplessness. Combined with baths, and applied generally over the sur- face of the body, it is of excellent service when the limbs are aching and stiff from over-exertion or exposure to cold. It allays the sensitiveness of the skin, leaves behind it a feeling of well-being and comfort, and does away with the sensation of fatigue. In sprains, how r ever, and injuries of like char- acter, its application is more limited. In recent cases, where there is no extensive laceration of ligaments, and where it is thought advisable to begin massage without delay, it may be used as a preliminary to allay the sensibility of the skin, and accustom the patient to firmer kneading. In old chronic cases, too, where the joint has. not been moved for some length of time, it is of undoubted use in restoring the natural tone to the skin before more active measures are undertaken. In other circumstances it is rarely employed for injuries of joints, though it is highly recommended as part of general massage for other disorders. Percussion, Percussion, too, whether carried out by means of an instrument or w r ith the hand, is of very limited use. Un- less applied with such force as to cause actual bruising, it has no direct influence on any structure deeper than the skin and the subcutaneous stratum of muscles. On the former it pro- duces the same general result as friction, though without its soothing influence; on the latter it acts as a local stimulus, causing each time a single contraction of the fibres beneath, varying in extent and vigor according to the condition of the muscles. To produce the full effect, the movement must be rapid and short, the pressure being raised at once. The weight of the blow must be regulated by the depth of the structure. Great stress is laid by some on the number per minute, when percussion is used for the relief of pain or neu- ralgia; but, so far as the muscles are concerned, this does not 1 24 Sprains ; their Consequences and Treatment. seem material, though it is as well the strokes should not be too rapid. The effect is most marked when the muscles are in a state of tension, though the actual shortening- produced in these circumstances may be less apparent. When, for example, the lumbar region is being percussed, the patient should stoop for- ward, so that the muscular slips lying along the side of the spinal column may be placed upon the stretch, and receive the full effect of the vibration. Otherwise a considerable amount of the benefit is lost before the muscular substance is affected at all. Massage. Massage, in the strict sense of the term, is a great deal more efficacious, especially with older sprains. Its action is not limited to the skin and superficial structures. These undergo immense changes, it is true ; they become softer and finer while under manipulation; their strength and elas- ticity increase, the extreme tenderness diminishes, and the natural appearance and texture return. The surface loses its dry harsh character and becomes warm and moist again; the livid bluish color gives way to a brighter hue, and the deeper layers of fibrous tissue yield and stretch, so that the hide-bound shrunken condition that is often present after long disuse gradually passes off. But the good effect is not by any means limited to, or even most conspicuously shown by this. When properly carried out massage exerts a simultaneous influence on muscles, nerves, and vessels, in fact on all the tissues within its reach. The circulation is the first thing to feel its power. It has already been explained how, after prolonged rest, the blood, as it were, lies almost stagnant in the tissues, slowly circulating through them, and neither giving them sufficient for their nutrition, nor removing from them the waste products of their action. This is changed at once. The life of the part is quick- ened. The veins and absorbents are emptied first, and the fluid they contain driven on to the heart, which fills more rapidly, and contracts more vigorously and firmly. Then the pressure falls on the smaller vessels, and the tiny irregular spaces, full of lymph, which extend in all directions through the tissues. These, in their turn, are compressed and me- chanically emptied, their contents being driven on into the empty vessels, from which any backward flow is prevented by Sprains ; their Consequences and Treatment. 125 the valves. The circulation becomes more rapid; nutrition is carried on with greater energy, and the actual amount of blood in the tissues at any one time so much increased that they become full and soft to the touch and regain the even and rounded contour of active health. Next to the skin the muscles seem to experience the great- est amount of benefit. Even after a single application they are capable of doing- a great deal more work with much less fatigue. It has often been shown that a muscle, exhausted by lifting- a heavy weig-ht many times in a minute, scarcely re- gains any of its power if it is merely allowed to rest a quarter of an hour. It remains stiff and weak, and liable to irreg-ular and spasmodic contractions. If, on the other hand, it is treated by massag-e for the same length of time, its strength returns, so that it is able to do as much again with even less fatig-ue than it felt before. At the same time the sensitiveness to electric stimuli is in- creased. Murrell has shown that a current, too weak to cause any response when applied to the motor point of one of the muscles of the arm, is able to produce vigorous contraction after a few minutes' massage. The excitability of muscles, and the amount of energy they are capable of putting out, are regulated other things being- equal by the way in which they are supplied with food, and the rapidity with which the waste products are removed. This, in its turn, is dependent on the circulation. Each muscle and each bundle of muscular fibres is surrounded by a sheath of fascia, to all intents and purposes quite inelastic; under this is collected the fluid plasma which is the immediate source of the nutrition of the tissues. So long- as the muscle is at rest this remains unchanged; when it contracts, so that the shape and consistence are altered, or when the muscle itself is thoroughly and systematically kneaded, the fluid is driven onward into the lymphatics and at once renewed from behind. It is for this reason that mas- sage, so far from causing- fatigue, is of such service in reliev- ing it. The good effect does not pass off at once. If the treatment is continued and a proper supply of food maintained there is a lasting increase in the size and condition of the muscles. In- stead of being soft and flaccid or stiff and unyielding, with hard and tender nodules in their substance, so that ihey rather 126 Sprains; their Consequences and Treatment. impede movement than otherwise, they become firm and elastic to the touch, ready to respond at once to any stimulus, and able, when called upon, to put out a much greater amount of energy. It is hardly fair, however, to attribute the whole of this im- provement to the condition of the muscles only. Massage ex- erts a similar influence on the nervous system, and though the immediate results may not be so striking- in their character, the actual chang-es are none the less important. During the process itself, and often for hours after, the patient experiences a sense of refreshing- ease and comfort. Lassitude and pain disappear; the capacity for work returns, and mind and body alike regain their vigor. Probably this results in no small measure from the improvement in the circulation, as the effect at first is quite local; but from the way in which g-eneral strength and voluntary power are restored, in what are known as neurasthenic cases, massag-e must exert a very considerable influence upon the whole of the nervous system. In Recent Injuries. The best proof, however, of the power it possesses over absorption and circulation is shown by the ease with which the swelling- and tension can be made to dis- appear from sprained joints. It is true that in recent cases the greatest care is required, and that nothing- is so likely to increase the mischief as rough handling of the part; but when it is carried out quietly and gently, by one who has had some experience, it is very difficult to find anything that acts in so perfect a manner. The whole limb, perhaps, is swollen; the joint distended with blood; the skin shining and tense, much too hot to the touch, and exquisitely tender ; but all this van- ishes almost like magic. The tension disappears as the fluid is carried off; the pain is relieved, the temperature falls, the natural outline begins to be apparent once more, extravasatecl blood is broken up, the debris dispersed, and adhesions be- tween the torn and bruised surfaces effectually prevented. Sometimes even tendons, which have been turned almost out of their grooves by the accumulation of fluid in their sheaths, can in this way be restored to their position without further assistance. Such results as these cannot, of course, be obtained in every case of recent sprain, and even when the treatment is success- ful in relieving- the pain and getting rid of the swelling, it Sprains ; their Consequences and Treatment. 127 must always be remembered that time is needed for the repair of structures that have been torn. I am convinced, however, that, especially when the stress of the injury has fallen on the muscles, and when the laceration is not too great, this plan may be adopted, not only with the greatest safety, but with an infinitely better prospect of speedy recovery than under the old established method of bandaging and rest. Graham, in particular, lays stress on the fact that the sooner the treat- ment is commenced after the injury, the shorter its duration is likely to be. In Older Cases. In older cases, where the effusion is denser and firmer, and where, owing to the long-continued distention, the tissues have lost their tone, and become sodden and cedem- atous, massage can be used with much greater freedom. The solid part of the effusion is broken up and disintegrated by the pressure, so that it is driven into the absorbents and carried away by the increased force of the stream; the chronic conges- tion is dispersed, the blood circulates more freely, the tone of the part returns, and the lifeless, helpless look disappears day by day. The improvement is often surprising in its rapidity. A joint that has remained for weeks cold and inactive, the seat of a constant wearing pain, and quite incapable of per- forming its proper movements, in a very few sittings begins to recover its flexibility, loses the pain, and allows itself to be handled, and passive movements to be carried out with ease and readiness. Active movement, in general, takes some time longer, for the muscles grow so stiff and rigid from prolonged disuse that they require as much education as the joint itself. The case that furnishes the most striking cure is a sprained joint that has been treated by bandaging in the conventional way, where the oedema still persists, and where there are no adhesions round other than those caused by the rigidity of the capsule and the swelling of the soft tissues. Even if weeks have passed, the effect may be seen after the second or third sitting. Only where, owing to the great length of time, the effusion has be- come thoroughly organized, and where the structures round are shrunken and matted together by dense, unyielding fibrous tissue, it is of little avail until the joint is set free, and full range of action restored by vigorous passive movement. Method. The method of application is not easy to de- 128 Sprains ; their Consequences and Treatment. scribe, and it can only be learned through practice, even by those who already possess a fair knowledge of anatomy. This is indispensable; without it, massage must degenerate into mere rubbing. Each group of muscles must be known, where it ends and begins, how thick it is, and how the tendons lie, where the intermuscular septa of connective tissue come, and where the vessels and nerves that supply the part are situated. All the natural movements and the different arrangement of the structures in various positions of the limb must be per- fectly familiar. The synovial cavity of the joints and the ten- don sheaths must, as it were, be mapped out underneath the skin. In short, there must be a thorough practical knowledge, not only of the anatomy of the part at rest, but of the direc- tion and mutual relations assumed by the different structures when at work. Supposing the case of a sprained ankle of moderate severity in a healthy person, a few hours after the accident the liga- ments are strained, perhaps even slightly torn; the synovial cavity is distended with fluid, the tissues round are swollen out with extravasated blood, the skin is hot and discolored, the normal shape of the joint is lost, and all the hollows between the bones are filled up. The patient must be seated comfort- ably, so that the muscles are, as far as possible, relaxed ; the knee must be bent, and the foot and ankle given over alto- gether to the manipulator. The foot is to be held gently but firmly, so that the patient may make no incautious start, and the whole proceeding from first to last should be entirely de- void of pain. The operator should have plenty of room, so that he is not cramped ; perhaps as convenient a position as any is kneeling on one leg, or sitting on a low seat in front of the patient, with the heel of the injured limb resting on the front of his knee. The movement at first must be exceedingly light, and so directed as to diminish as much as possible the sensitiveness of the skin, commencing with the part above (nearer the trunk) the injured joint, and working gradually downward. The thumb, or the tips of the fingers, or the palm of the hand, should be used according to the shape of the sur- face, taking care always to employ as much as possible. The direction of the movement must always be toward the trunk, from the insertion to the origin of the muscles, in the direction of the returning current of the circulation, com- Sprains ; their Consequences and Treatment. 129 mencing over a part where the swelling 1 has not yet shown itself, and gradually working- on to the rest. The most tender spots must always be left till last. If, for example, the foot has been twisted outward, there is nearly always great sen- sitiveness over the tip of the internal malleolus, and a consid- erable amount of swelling- along- the course of the tendons behind, extending- a variable distance up the leg, and into the hollow in front of the tendo-Achillis. This must be left until friction has been applied over the whole of the rest of the foot and leg-; if this is carried out thoroughly not only does a great deal of the swelling disappear of itself from the injured part, but owing to the condition of the circulation through that which has been already manipulated, the remainder is ab- sorbed much more readily than it otherwise would be. Gradually, if the treatment is persevered in, the tendency to start on the part of the patient, and even the involuntary shrinking, disappear; the foot is given up to the operator with greater confidence, and the superficial general swelling begins to diminish. More attention may then be paid to the spaces in which the extra vasated blood has collected to the cavity of the joint and the tendon sheaths. The tips of the fingers, or the thumb, may be made to trace out the irregular intervals be- tween the bony prominences moving round and round in small circles on the skin. The two hands should be used close to- gether, so that the paths the fingers traverse intersect each other, and the manipulated surfaces overlap. Gradually, as the effusion subsides, the circles increase in size, the pressure becomes firmer, and the deeper-lying structures are treated in their turn. The individual muscles and tendons are grasped and squeezed in the direction of their fibres, the fingers being al- ways carried onward toward the trunk in the interspaces be- tween them ; and the soft tissues are firmly pressed, and, as it were, rolled along by one hand after the other, until all the excess of fluid has returned once more to the blood stream, and slight passive movements of such a nature as not to exert any traction on the injured ligaments are allowed without resist- ance. This is to be taken as the sign of success in the treatment of recent cases. How long before it is reached differs natu- rally in each individual, and no rule can be laid down. Some- times in slighter injuries a single short sitting suffices; at 13 Sprains ; their Consequences and Treatment. others the process must be repeated for several days. The time that has elapsed since the accident, the condition of the joint, the degree of swelling-, and the severity of the pain, all possess some degree of influence. As a general rule, if the injury is recent, there is more tenderness about the part, but the swelling* disappears sooner; in older cases firmer pressure may be used from the first, as the skin is less sensitive ; but the time before the swelling is absorbed, and movement be- comes free and painless, as a rule is much longer. At the close of the sitting the joint and the limb must be bandaged with pads of cotton wool, so arranged as to fill in all the natural depressions of the part. If they are held in place with a flannel, or better a Domett bandage, the joint may be moved a little, though the pressure is sufficient to pre- vent the return of any great degree of swelling and oedema. But, however carefully the bandage is applied, it nearly always happens that the next day some of the fullness and tenderness of the part returns, so that another sitting is desirable. If the case is g-oing to terminate favorably, each application is shorter and less painful than the last, and each time the range of passive movement is increased. It must clearly be borne in mind that, though this method of treatment causes the swelling to disappear more rapidly than any other, and allows the return of slight degrees of movement without pain almost from the first, a ligament that has been torn across requires nearly as long for repair as when it is left alone. Consequently, when it comes to the question of dealing with sprains of great severity, such as often are met with in the ankle, all that is done, and, indeed, all that can be done, is to restore the parts to the condition best suited for repair, and to guard, as far as possible, against the after troubles of stiffness, chronic oedema, and pain. In older sprains, the method of application is somewhat different. Here much less stress is laid upon light friction, and much more upon deep manipulation and rolling of the parts. The object is not so much to cause the absorption of a fluid exudation as to stimulate the muscles and nerves to greater activity, and to increase the amount of blood and lymph circu- lating through the deeper strata. The grasp is firmer, and the pressure greater; the whole hand is used, and both at the same time; if, for example, the limb is not too large, one may Sprains ; their Consequences and Treatment. 131 be placed opposite the other, so that two groups of muscles are manipulated tog-ether, the fingers of one hand partly reaching on to the territory of the other. One hand contracts as the other relaxes, each, in its turn, squeezing- the tissues onward and away from the middle line, and stretching the parts that lie between them. Care, of course, must be taken not to stretch the tissues in opposite directions at the same time; and it is a wise precaution to go over the surface gently and superficially before attempting deep or thorough manipu- lation. Where other joints are concerned, the treatment must be conducted on essentially the same principles, varying the de- tails according to the circumstances of each case. The opera- tor should always keep sufficiently far off so that his move- ments are not cramped or constrained, and he should always endeavor to make use of as much of the surface of his hand as possible. The fingers must be kept close together for the sake of mutual support; the}" should not be allowed to slip too much upon the skin, which should move with them as far as possible, or the operation may be a very uncomfortable one for the patient. For this reason ointments and other similar applications are very rarely used unless it is wished either to diminish friction or to produce some specific effect. The patient must be placed in an easy and comfortable position, with the limb well supported, and, where possible, well raised, so as to assist the return circulation. If, for ex- ample, the wrist is the part in question, the point of the elbow should be resting on the table; if it is the elbow itself, or the shoulder, the patient should either rest his hand on the shoulder of the operator, or should even lay hold of something higher still. The hands must always lie in the direction of the muscular fibres, and the rolling and squeezing always tend upward from the extremities toward the trunk. The rate of move- ment and the amount of force that is used must vary with each individual; but there should never afterward be am- sign of bruising due to the manipulation. It is always pres- ent, of course, to a greater or less extent, in recent sprains, and it is nearly certain to be there if adhesions are broken down or a joint is forcibly manipulated under an anaesthetic; but it never occurs after massage unless the force used has been ex- I3 2 Sprains ; their Consequences and Treatment. cessive and unjustifiable, and its presence generally means that more harm than good has been done. Instead of assist- ing- in the repair of the damage it has inflicted more. It is most essential to commence as gradually and as gently as possible, only working on the deeper tissues after the more superficial ones have become thoroughly accustomed, and have been unloaded of their surplus fluid. The skin, the soft subcu- taneous tissue, the muscles, and the deeper layers, must all be worked in turn. Nor should the manipulation be confined to the injured part. In a sprain of any standing the whole of the limb is affected more or less. It is usually better to de- vote attention first to the parts nearer the trunk, than to deal with those around the injured area, and only afterward, when the circulation is thoroughly re-established, to manipulate the joint itself. The tendency is to make the sittings last too long. Deep manipulation itself rarely requires more than five minutes; but in dealing with a recent injury it may be advisable to spend a longer time than this over the friction and other pre- paratory measures, so that a quarter of an hour soon passes by. When the tenderness is very great, and the amount of swelling- excessive, much longer than this may be necessary, but short, frequently repeated sittings are of greater benefit than one long one. A skilled operator, too, will often effect more in a few minutes than an ordinary rubber will in as many sit- tings. CHAPTER XI. SPRAINS OF TENDONS. SPRAINS of tendons are deserving- of as much consideration as those of joints; they are almost as common; the changes in the tissues are nearly as serious, and the results, though they vary a good deal, are in many respects quite as impor- tant. Unless perfect freedom of movement is regained, there is an amount of suffering- and inconvenience often altog-ether out of proportion to the extent of the mischief. Structure. In one respect the question is much easier; the structures concerned are not nearly so complicated. The shorter tendons are merely unyielding- bands of various shape, directly connecting- the muscle to one of the adjacent bones. They are formed of tough fibrous tissue, continuous, on the one hand, with the membrane investing the bone, and, on the other, spread out to receive the attachment of the muscular fibres. The longer ones are more or less rounded in shape, and are inclosed in a synovial sheath, practically identical with that which lines the interior of joints. The surface is as smooth as it can be, so that the tendon glides without friction in its groove, no matter how many bends or curves it makes, or how often the position and direction of these vary in different move- ments of the limb. The interior is lubricated by a fluid identi- cal in character with that in joints, just sufficient in amount to fill up all the interstices, and enable the sheath to fit closely and evenly round the tendon. The outer wall is formed of a fibrous layer, which, though apparently distinct (just as the capsule of a joint appears distinct), is only a layer borrowed, as it were, from the delicate tissue round. Owing to the fric- tion, this is condensed into a firm membrane, smooth and polished on its inner surface, but roug-h on the outside, where it still retains its connection with the fibrous tissue from which it was formed. In some parts of the body each tendon has a separate ! 34 Sprains; their Consequences and Treatment. sheath surrounding 1 it like a tube. At the ends this is con- tinuous with the sides of the tendon, so that the cavity is com- pletely closed. It is largest and best developed where there are projecting points of bone, and where the direction of the pull is consequently altered. In many parts the sheaths of two tendons lying 1 side by side communicate with each other; and where, as an the wrist or ankle, the number of those run- ning 1 in the same direction is considerable, there is only one large sac surrounding 1 them all. Sheaths of this description are much stronger and stouter, the walls are thicker, and owing to the bundles of tendons lying side by side, each move- ing independently of the rest, are ribbed, as it were, on the inner surface with longitudinal ridges, w r hich sometimes pro- ject as actual folds, inclosing between their layers a mass of soft and delicate tissue well supplied with minute vessels. In the young the lining membrane itself is quite smooth, so far as its inner surface is concerned; but as age advances, par- ticularly in those whose work is laborious, or whose joints and tendons are exposed to heavy or repeated strains, it undergoes great alterations. The folds grow stouter and longer, their free margin becomes irregular and broken up into fringes, and the tissue of which they are composed becomes tougher and firmer, until in some instances the surface is as irregular and as shaggy with villous processes as the interior of a joint affected with chronic synovitis. Effects of Age. This, however, is not the only alteration found in tendon sheaths after adult life. There is a slight but constant tendency for them to enlarge and encroach on sur- rounding structures. Where two lie side by side, or where one is in contact with the capsule of a joint, the dividing wall in course of time grows thinner and thinner until it gives way altogether, so that the cavities communicate with each other. In other instances, where the tissues round are soft and yield- ing, the sac expands unevenly, and becomes covered over with irregular dilatations. If the wall is especially weak at any one spot, or if from some accident the fibrous layer of the sheath has been torn, the lining membrane is forced out little by little into the interspace, until it assumes the shape of a pouch, opening into the sheath by means of a long and some- times very narrow neck. When one of these is once formed it generally continues to increase in size. Fluid is driven into it Sprains ; their Consequences and Treatment. 135 with, very considerable pressure every time the tendon moves without there being 1 any corresponding- force to insure its return; the sac grows larger and larger until it projects be- neath the skin, or even opens up a communication with some more distant cavity. It is in this way that tendon sheaths become connected with neighboring 1 joints, the pouch devel- oping- originally sometimes from the one, sometimes from the other. In the majority of instances it is difficult to say how far these changes are the result of time alone, and how far they are the product of repeated sprains, and of attacks of rheu- matic gout. In joints there is no question that these causes are of material assistance, to say the least. Whenever large diverticula are present, or the interior of the synovial mem- brane is more than usually irregular, one or other of these has been at work. The same is probably true of tendon sheaths and of bursse; the alterations are not serious except under these conditions. Slighter degrees, however, tending in the same direction, but not going further than a moderate amount of dilatation and thickening, are so common, and so consistent with what takes place under the same conditions in similar structures, that there is no doubt they are due, in part at least, to the natural degeneration of the tissues occurring everywhere as age advances. Extent o/ Injury. The tendons themselves rarely sustain much injury in the case of sprains. They are formed of little more than tough bundles of fibrous tissue closely woven to- gether, so that if they escape being torn in two, or wrenched from the muscle to which they belong, they generally escape altogether. The sheaths, however, in which they lie make up for them in this respect. They are so delicate in structure hat they are torn or bruised by the least unusual strain, and the relation they bear to the tendon they inclose is so accurate that the slightest alteration is sufficient to produce a very- considerable effect. Overwork. Serious consequences are, of course, much more likely to be produced by violent injuries, but mere over- work is sufficient to affect the synovial lining and to cause in- convenience and actual pain. It need not be excessive; it is enough that it should be more than usual, and that it should be kept up for some time. Instances of this are of every-day 136 Sprains ; their Consequences and Treatment. occurrence when an unusual degree of exertion falls on a group of muscles that are not accustomed to it. The movements of the tendons are no longer easy and natural ; a hot, burning- sensation is felt each time the muscle contracts; there is a feeling of tenderness and fullness over it; the temperature (as taken by a surface thermometer) may even be slightly raised, probably from the larger amonut of blood that is flow- ing through the part; and, what is the most striking and characteristic symptom of all, as the tendon plays backward and forward in its sheath there is communicated to the finger a delicate sense of crepitation and rustling", as when two sur- faces of silk are being rubbed tog-ether. Sometimes this is perceptible to the patient himself, at others it can only be elicited by carefully applied pressure over the tendon sheath. Whenever it occurs it may be accepted as clear proof that there is some alteration in the relation between the tendon and the membrane round it. Naturally it can be felt most plainly where a number lie close together beneath the skin, as on the front of the ankle joint or the back of the hand. In situations such as these, any unaccustomed degree of exertion, walking, for example, some distance unusually fast, or feather- ing- in rowing- at the commencement of the season, or even car- rying a heavy weig-ht in the hand, is sufficient to cause it. Tenosynovitis. It has been imagined by some that this peculiar sensation is the result of the sheath becoming dry. The synovial fluid is, as it were, used up, and the movement of the tendon over the dry and roughened surface causes friction. It is very difficult to understand how this can occur; such a condition of thing-s would be almost unique ; nowhere else does use, even when carried to the greatest excess, entail any simi- lar result. The immediate effect of muscular contraction is to increase very larg-ely the amount of blood flowing through the part, and to cause a much larger quantity of lymph to pour out through the walls of the vessels into the surrounding tis- sue spaces. It is difficult to understand how, under such con- ditions, the sac of the synovial membrane could become dry. The walls contain a greater amount of blood, they are softer and thicker, the lining layer of cells is not so perfect, their growth is more rapid, so that they have no time to assume their normal flattened shape, and the character of the fluid in the interior is modified by being mixted with the exuded lymph Sprains ; their Consequences and Treatment. 137 and with the cast-off cells; but the quantity is rather increased than diminished. Lawn Tennis Arm. The same symptoms (with the excep- tion of the rustling 1 ) are produced by over-exertion when the ten- don is attached directry to bone without the presence of any in- vesting- sheath of synovial membrane. A common instance of this is met with in a variety of what it is the present fashion to call lawn-tennis arm, though a similar thing- Avas described long- since in Australian dig-g-ers. There is a tender spot about the middle of the forearm, on the outer side of the bone, cor- responding- to the attachment of one of the muscles that is used especially in back-handed strokes; and sometimes the tenderness is so great that I have known it the source of great uneasiness. The skin appears slightly swollen and raised above the normal level ; but it is quite white, even whiter than the surrounding- part, and the swelling- so soft that it can be appreciated much better by the eye than by the touch. In moderate cases it is limited to this point, and the muscle itself is not affected ; only when it contracts there is a feeling of soreness and stiffness, not, perhaps, amounting- to actual pain. In severe ones the swelling- extends over the whole muscle. The changes here are essentially the same; owing to the increased wear and tear more blood flows through the part ; a larger amount of exudation is poured out into the tissues, through the walls of the vessels ; the skin becomes more highly sensitive, so that it feels sore and tender when even light pressure falls on it; and the action of the muscles is difficult and painful. Only there is no crepitation or rustling, because there is no synovial sheath in which the fluid can collect. Muscular Strains. Under some circumstances the exer- tion required to produce such a result may be exceedingly trivial. It is not uncommon for patients who are recovering from an attack of severe illness, when they are allowed to sit up for the first time, to complain, after an hour or two, of sore- ness over certain bony prominences, and of a sensitiveness of skin that is sometimes mistaken for hysteria. There is a line, for example, at the back of the head, or a space between the shoulder blades, where the least pressure is painful, especially after they have been sitting up some time. In the morning, or after a long rest, nothing of the kind is felt; the muscles can act freely and naturally. It is only when they are tired out 138 Sprains ; their Consequences and Treatment. that these symptoms begin to appear. The work that they are called upon to perform is too much for them; they have been weakened to such an extent by prolonged illness and want of exercise that the exertion of sitting- uprigiit is as much out of proportion to their strength as severe and prolonged labor would be if they were in good training. There is, it is true, no appreciable amount of swelling, but it is quite suffi- cient for the purpose that the tender points of bone correspond with very fair accuracy to the attachments of the muscles that receive the strain. Rest at once relieves it, and as the nutrition improves and strength returns the symptoms rap- idly disappear. The same thing is frequently met with in connection with the abdominal muscles after vigorous efforts of any kind, and it is sometimes so marked that I have known it mistaken for more serious disorders, especially as the muscles are often thrown into a state of cramp, so that they do simulate, to some extent, internal tumors. There is the same burning sen- sation when contraction takes place; the skin feels tender and sore, and its sensitiveness is extreme (as it frequently is in hysteria), the patient wincing at the slightest contact. Some- times the feeling of soreness is worst over the points where the muscles are attached to the bone ; but more often the patient refers it to the junction of the muscular and tendinous fibres ; and it is remarkable and very characteristic of this muscular overwork, that nearly always, in indicating the seat of the pain, the patient moves his hand, quite unconsciously, in the direction of the fibres that have had the severest strain. Injury to the Sheaths of Tendons. In sprains, however, the trouble is generally more serious, and the symptoms more definite. When, for example, a man falls down with his hand and forearm doubled up beneath him, so that the whole of the stress falls on the tendons at the back of the wrist, and the soft and delicate tissues lying underneath are crushed against the bone, the amount of damage sustained is not to be mis- taken. Within a very few minutes the wrist swells up, the tissues are bruised, the vessels torn across, and blood poured out into the tendon sheaths and the structures round, just as it is when any other part of the body is injured. Only because there is a sac in which the fluid can collect, the swelling is unusually rapid in making its appearance, and is limited at Sprains ; their Consequences and Treatment. 139 first in shape. Soon, however, it begins to spread; the back of the hand swells up, though here it always feels softer than it does elsewhere ; then it extends along the forearm, and even makes its appearance on the front of the wrist, probably be- cause the tissues in this situation were crushed and squeezed at the moment of the fall. The skin becomes hot and tender; movement at the wrist is completely lost; the joint is kept nearly straight, and can neither be bent nor extended; the for- mer movement is too painful, because then the extensor tendons are pressed against the part of their sheath that has already sustained the severest hurt; the latter is almost impossible, as tendons cannot work when their sheath is distended with fluid. Even the fingers suffer in the same way; though a cer- tain amount of flexion is permitted, they cannot be bent into the palm of the hand or completely straightened out. After a few days the bruise begins to come out near the elbow (generally on the front surface of the joint) and, per- haps, in the hand; the coloring matter from the blood soaks by degrees into all the surrounding structures, and spreads along the looser planes of cellular tissue until it reaches the skin. The swelling slowly diminishes, remaining longest over the tendons ; the tenderness becomes more definitely localized, being chiefly felt over that part of the back of the wrist which corresponds to the spot where the tendons were most bent and crushed against the edge of the bone ; the movement becomes more free; the amount of grating and creaking grows less and less, and if no adhesions have formed, and there are no other troubles to hinder the progress of recovery, voluntary power slowly comes back, though even in a moderately suc- cessful case it is sometimes months before all the thickening has disappeared and the joint can be completely flexed. Inflammation. Sometimes it happens that instead of the extravasated- blood being absorbed, and the movements re- turning in this way, inflammation sets in either as the result of some constitutional predisposition, such as gout, or from the excess of tension in the tissues. Ordinarily speaking, it is not present at all. The changes which have been described above are identical with those that accompany any severe bruise; the swelling has been already accounted for; the in- creased amount of blood flowing through the part, causing the skin to become hot and sometimes red. and making it at the 14 Sprains ; their Consequences and Treatment. same time more sensitive to pressure, is only what is required by the increase in the need for repair; the pain is due to the tension caused by the extravasation and effusion; and the loss of mobility is the result in the early stages of the distention of the sheath (for unless the tendon is tightly grasped it loses all its power) and of the pain when the torn and bruised tissues are pressed on; in the later ones, of the imperfect absorption of the lymph that has been thrown out and of the stiffness caused by prolonged rest. These are the great causes of the delayed convalescence and of the obstinate rigidity that so often follow such injuries. In the majority of instances there is no more inflammation after these than there is after a sim- ple fracture or a severe bruise. When it does break out the severity of the symptoms is not easily mistaken. The pain is intense; it is no longer a question of a hot or burning sensation felt when an attempt is made to move the tendon; the whole extremity throbs from one end to the other. The temperature rises rapidly ; the skin grows red, and, if suppuration is going to follow, becomes thick and swollen, so that it pits on pressure and can no longer be raised up from the structures that lie beneath. At the same time there is high fever, with headache and constitu- tional symptoms of great severity. Inflammation of this description rarely remains limited to the space in which it begins. Sheaths of tendons and bursce are, so far as their development is concerned, merely great in- terspaces in the cellular tissue, and they never lose their con- nection with the others around them. If they become in- flamed, and their contents suppurate, the way lies open for the pus to spread through all the cellular tissue of the limb. It may even extend into the neighboring joints without there being of necessity any direct or open communication between them. I have many times seen complete destruction of an articulation, even of such a one as the knee, occur as a result of deep-seated suppuration that had found its starting-point in the inflammation of a neighboring bursa or tendon sheath. Imperfect Recovery. Imperfect recovery, stiffness, and loss of power are much more common. For a week or two everything goes on well; the symptoms gradually diminish in severity; the pain becomes less and less; the swelling disap- pears, except immediately over the tendons (there it always Sprains ; their Consequences and Treatment. 141 lasts the longest), and a certain amount of voluntary move- ment is regained. But then the improvement stops. Every attempt at further progress is checked at once by pain, and is followed by an increase in the swelling. The muscles begin to waste; the neighboring joints and tendons become stiff from prolonged disuse; and sometimes the improvement already won is lost again, and free movement of the tendons never re- turns completely. There is no doubt that this is much more likely to happen if the tendon sheath has been inflamed, and that then the re- sults are, generally speaking, much more serious. Even when it subsides fairly soon, inflammation, if it once involves a ten- don sheath, always leaves behind it extensive, and sometimes permanent, changes. But it is also certain that loss of move- ment, and other troubles, are met with after injuries of ten- dons in which inflammation never occurs at all. Complete and permanent wasting of the muscles, and an absolute degree of rigidity, may be uncommon; but, independently of these, sprains are liable to be followed by a number of other conse- quences, which have nothing to do with inflammation, and which are quite sufficient to give rise to the gravest incon- venience, and even to prolonged suffering. Stiffness, for example, is rarely absent altogether. Some time always passes before the tendons move, as they ought to do, so easily that there is no consciousness of their existence. Pain is equally common, and, indeed, is in general severe in pro- portion to the stiffness. It differs immensely in different cases. In some there is a constant sense of aching, and of soreness over the whole part, even when it is at rest. In others it is only felt on movement, and then with great severity over cer- tain spots. Swelling nearly always persists for a time. The sheath is distended with fluid, or cysts develop in connection with it ; or there is some effusion into the cellular tissue round, sometimes soft and yielding, at others hard and irregular. It may continue without material change for an almost indefinite time; more often it increases slightly in amount as often as the tendon is much used. The skin may remain exceedingly tender, especially over those spots where the swelling is greatest, or where pain is felt when the tendon is moved. Creaking and grating are almost universal. It is not merely the delicate rustling, already mentioned, due to the alteration 142 Sprains ; their Consequences and Treatment. in the lining cells, or to blood or lymph being 1 mixed with the synovia, but a much rougher, coarser sound, caused by the presence of fringes, projecting up from the folds of the lining membrane, like those in joints; or else by myriads of loose bodies floating about in the fluid, in which the tendon lies and moves. Louder noises even may be audible in the later stages, caused, in all likelihood, by the sudden separation of two sur- faces that accurately fit each other. Very often there is a peculiar feeling of weakness not so much actual loss of power in most cases as a sense of inse- curity. It occurs even with an ordinary ganglion on the back of the wrist, and is almost invariable when one of these is large enough to project distinctly under the skin. The patient complains of inability to use the hand, the flexor muscles being as much interfered with as the extensor, owing, no doubt, to the way in which they are always trained to act together. When the dilatation involves the sheath itself, the sensation is never wanting. I have seen an instance in which a patient was quite unable to bend his middle finger, merely because the sheath of the flexor tendons along the under surface was dis- tended with fluid. There was no other obstacle ; it could be bent by the other hand, as far as mechanical considerations would allow; and as soon as the fluid was removed by subcu- taneous puncture, full power was regained. Even this does not exhaust the list. There are other con- sequences following sprains of tendons, similar to those already described in the case of joints, involving parts that have not sustained any direct injury. Wasting, rigidity, and loss of power in neighboring muscles; stiffening of the capsules and sheaths of other joints and tendons; filling up of the cavities of bursse and other periarticular spaces; and many others which are probably the result of prolonged rest and confine- ment in one position, rather than of anything else. Inflam- mation, when it does break out, makes them all tenfold worse; tout it is not by any means necessary for their occurrence. The injury sustained when a tendon sheath is badly bruised, and then kept perfectly quiet for an indefinite length of time, is quite sufficient to account for them in most cases without calling in the aid of anything else. Treatment. So far as general principles are concerned, the treatment of tendons, after they have been sprained, is very Sprains; their Consequences and Treatment. 143 similar to that already described in the case of joints. The great object is to restore the power of voluntary movement as soon as possible; everything else must be subordinate to this. Until this is perfect, recovery cannot be said to be com- plete. The first obstacle is the extravasation of blood into the tissues, and the amount of lymph poured out afterward to effect the repair of the injury. The soft and vascular tissues, some of the most delicate in the body, are crashed and torn ; blood flows out in all directions, until, if it is not checked in some way, the sheath and the cellular spaces round can con- tain no more. Then all the vessels dilate; everything 1 swells up and becomes soft ; the interstices in all directions are dis- tended with lymph, which gradually takes the place of the blood as this is absorbed ; and if no steps are taken to prevent such a result, the tendon, its sheath, the delicate tissues round, and even the neighboring- muscles and fasciae, so far as the in- jury has extended, become glued together. Of course, the ex- tent to which this change takes place in the different tissues varies within very wide degrees. The tough, unyielding, and almost non-vascular substance of which a tendon is composed scarcely shows the change at all, while the soft and delicate tissue round and between the folds of the synovial sheath is so altered that it can hardly be recognized; but the principle is the same. The change is an essential one, the natural conse- quence of the injury, and has nothing to do with inflammation. Under certain conditions it may be carried to excess, and then it becomes a source of danger, and may even, by the help of other agencies, become the starting-point of this complication, the cause rather than the consequence. But this ought never to happen, and if the effusion can be restrained within proper limits, and the predisposing causes are not too strong, never does happen. No doubt inflammation follows if a patient, who is on the verge of an attack of gout, by some fall, strains or otherwise injures one of his tendons. It is only natural that it should, and it may come on within an hour after the acci- dent, but it is not fair to put this down entirely to the credit of the injury. There is another reason for trying to check the effusion as soon as possible. After tendons have been sprained there is always a certain degree of stiffness. This is dependent on 144 Sprains ; their Consequences and Treatment. many things, and cannot be helped at first. But the perma- nence of this stiffness, and its degree, are regulated almost en- tirely by the extent of the effusion, and by the changes that it undergoes. If it is slight and quickly reabsorbed, leaving only so much as is needed for the repair of the tissues, perfect move- ment is recovered spontaneously; but when it is excessive, and all the surrounding structures are softened and infiltrated, this can only happen under the most favorable conditions. As a rule, much of it becomes organized; and then all the tissues are made stiff and rigid, and are matted together by adhe- sions. The minute interstices between them, for the purpose of allowing free and even play of movement, are filled up. Probably during life they contain a semifluid material, so that the structures on either side can easily accommodate each other in their various movements; this quite disappears. In worse cases, the opposite surfaces grow together, and the ten- don becomes adherent to its sheath, either in places, here and there, so that fibrous bands pass across from one to the other and limit the range of action, or even all over, so that recovery, so far as movement is concerned, is quite hopeless. Pressure. Heat or cold may be tried at first, as already directed in speaking of joints, but by far the most efficacious method is to apply well-graduated pressure from the very commencement. The details, of course, must vary in each case, but when this can be done systematically, not as band- aging ordinarily is, with the whole of the pressure on the bones, nothing succeeds so well. Only there must be a thorough knowledge, not only of the structure and arrange- ment of the parts, but also of the exact nature of the injury sustained in each case. Massage. Massage or kneading is even more useful in the treatment of sprained tendons and muscles than it is in the case of joints. The second day, when the pads and bandages are removed, the limb appears misshapen from the pressure to which the soft tissues have been subjected, and stiff from their confinement. Kneading and working the part thoroughly every day causes this to disappear more rapidly and more effectually than anything else. It must, of course, be done with a definite idea of the purpose in view, and with a knowl- edge of the structure of the part itself. Further, as the acci- dent is so recent, the ordinary rules must be observed with Sprains ; their Consequences and Treatment. 145 even more than usual care. The rubbing 1 at the commence- ment must be very light, affecting- only the skin at first, and then later the deepest structures. Tender spots must be ap- proached very carefully ; they need even more attention than the rest, but, unless it is very cautions, manipulation makes them more painful still. Every movement must be commenced at the end of the limb, working gradually toward the trunk. Properly managed, and used at the same time as passive motion, the relief this gives is immense ; the pain is exceed- ingly slight ; the swelling- disappears more rapidly than it does under any other method, and the chances of after stiffness are materially lessened. Passive Movement. There are the same rales with regard to passive motion. It must be employed reg-ularly and sys- tematically every day without fail. The loose tissues round the tendon sheath are softened and thickened ; the surface of the sj^novial sac is rough from the rapidity with which the new cells are formed to line it in place of the old ones; and it is irreg-ular from the swelling- of its folds and fringes. Unless movement is kept up from the first this must end in some de- gree of stiffness. It need not be repeated often at each sitting-; once is quite enoug-h, but it must be thorough. Every joint and every tendon near the part that has been injured must be worked at least once a day through its whole range of action. Slight and faint-hearted attempts, apparent movements really taking- place at another joint, are useless, and throw discredit on the treatment. They do not prevent the formation of ad- hesions, or break down those that are already established; they merely pull and strain on the stiffened structures round, and make them painful and tender without setting- them free. The adhesions, before they are too firm, are easily separated by definite and well-regulated manipulation without any fear of exciting inflammation. Even after they have become organ- ized it is safer, as has already been shown in speaking of joints, to break them down thoroughly and effectually with one single effort than to keep perpetually straining and worrying- them. Weak and ineffectual attempts, carried on hap-hazard, without any definite object in view, do more harm than good. They increase the pain that is left, cause more lymph to be poured out, prevent the absorption of that which is already there, and allow it to accumulate until, as the adhesions grow thicker 146 Sprains ; their Consequences and Treatment. and stronger, the prospect of recovery becomes more remote than ever. In the later stages, when the signs of cruising have nearly disappeared, if the movement of the tendons remains painful and constrained, and particularly if the patient can point out certain spots which are especially tender after use, more ener- getic treatment is required, just as in cases of imperfect re- coverj 7 after sprains of other parts. Baths, douching, and shampooing may be tried with success in many instances. Tendons, even when very stiff, nearly always move more freely after long soaking in hot water, and though they may not re- tain the whole, there is nearly always a certain amount of per- manent improvement. Galvanism, too, in these circumstances is sometimes of great assistance in encouraging the circulation and restoring muscular vigor. Stimulating liniments, espe- cially those containing the aromatic oils, are also most useful as adjuncts. They increase the flow of blood through the super- ficial parts, soothe the pain, and loosen and improve the nutri- tion of the skin. In this way they are of assistance to other measures which they cannot replace. If there are large and tender muscular masses, which remain stiff and painful, acu- puncture often acts with good effect, as described in speaking of sprains of the back; and counter-irritants and small light blisters, often repeated, are of excellent service in many of these cases. If, however, the tender spots are very definitely marked, and if they become more painful and tender regularly after certain movements, these methods are rarely sufficient to secure more than mere temporary relief. Something further is required. More Permanent Changes, Adhesions, etc. It may be that there is the residue of an old organized blood clot, outside the sheath altogether, forming a little hard, irregular mass, that is pressed on in certain positions when the tendon is stretched. I have known this it the neighborhood of the knee, in the fibrous expansion given off by the extensor muscle. It was merely a little blood clot, following a blow, lying under- neath the fibres; but probably there was a nerve filament near it, for the least contraction of the muscle gave rise to an amount of pain seemingly out of all proportion. I have little doubt that the same thing sometimes occurs in connection with deeper tendons. Sprains ; their Consequences and Treatment. 147 In other cases there is an adhesion, or some thickening- on the tendon sheath, or there are fringes or loose bodies in the interior continually shifting- their position, and keeping- up a certain amount of effusion, by the way the sheath is bruised when the tendon moves over it. It is extraordinary what a degree of pain and tenderness may be caused by a body of this kind, whether in a tendon sheath or bursa. Quite re- cently a patient, a woman of middle age, with rather stout and shapeless limbs, was sent to me, complaining that she had received a blow on the knee about a month before, and that ever since she had suffered such an amount of inconvenience that she could scarcely get about. Walking had become very painful; going upstairs was bad, but coming down she had such a sense of insecurity that she was obliged to cling to the banisters, a statement which I have often heard when there was anything interfering with the action of the extensor of the knee. On examining the joint, it appeared slightly en- larged, but most of the swelling was below the knee-cap on each side of the ligamentum patellae, caused apparently by the enlargement of the bursa, which exists naturally in this situa- tion, and which is always larger and more prominent in women than it is in men. It was over this that she had received the blow, and here on firm pressure could be felt a large loose body, which, when the muscle was relaxed, slipped easily under the ligament from one side of the joint to the other, causing each time a very peculiar and sickening sensation. In the same way I have on several occasions been able to trace the development of foreign bodies in the bursa lying in front of the knee-cap. In this situation they give rise to little inconvenience, as a rule, until in kneeling down and reaching forward the weight of the body is brought to bear upon the patella ; then there is a sudden stab of acute pain, and within a few hours the bursa becomes filled with fluid. Sometimes there is only one, irregular in size and shape, but often, owing probably to the repetition of the injury before advice is sought, the number is very considerable; or if the first is due to injury, the others may result from the persistent degree of irritation, and even of inflammation, maintained by its presence. When the pain can be traced definitely to a cause of this kind, there is no alternative. The patient must be placed under an anaesthetic to avoid suffering, and to secure complete 148 Sprains ; their Consequences and Treatment. muscular relaxation ; the part must be thoroughly examined, and the adhesion, if one is present, broken down, or the foreign body removed. Whatever the cause of the continued tender- ness may be, it very rarely happens that it is of a nature to be cured by prolonged rest. In the great majority of instances it is due to this having been too much prolonged already. Most of the crippled joints and tendons that are met with after sprains are due* to the fact that passive movement has not been employed sufficiently early or sufficiently thoroughly; and they are only to be cured by the adoption of measures that must be energetic in proportion to the delay. Ganglions. Some of these after-consequences, ganglions, for example, require a certain amount of notice, as they either do not occur in connection with sprains of joints, or, when they do, must be treated in a special way. There are two varieties of these ; one is a small cyst, originally in connection with the sheath, and probably due in the first place to a protrusion of the sac through a weakened or ruptured part of the wall; the other is a dilatation of the sheath itself. There is no essential difference between these, so far as their origin is concerned; they both frequently originate in strains, though it is possible some may arise from inflammation or in other ways; they contain the same kind of fluid, a clear gelatinous substance, much thicker than natural, and devoid of all lubricating power; and it is often possible to find transition forms between them,, sheaths, that is to say, irregularly distended, so that they appear to be sacculated; but the symptoms to which they give rise, and the method of treatment to be adopted, are very different. The former are by far the most common, and occur with especial frequency on the back of the wrist, where they give rise to much annoyance by their unsightly appearance, and by the sensation of weakness that accompanies them. They are met with, however, as well on the foot, on the outside of the knee, just by the head of the fibula, and in other places; indeed, there is hardly a tendon sheath in the body from which they do not sometimes project. As a rule, the inconvenience they cause is not serious, but it is not uncommon to meet with instances in which neuralgic pain of a severe character is a prominent symptom, probably because some small cutaneous nerve happens to be pressed upon by the cyst in certain posi- tions of the limb. Sprains ; their Consequences and Treatment. 149 Simple Ganglion. The ordinary method of treating- these is to crush them by direct pressure, and then gradually squeeze the contents into the surrounding- tissues, so that they may be absorbed, assisting the process from time to time by friction and kneading-, or by the pressure of a leaden plate. Or they may be punctured, and the fluid let out, and if they fill again, injected with iodine, or a small seton passed through them. Or a small tenotomy knife may be introduced on one side of the cyst, and the whole mass divided in two by a horizontal cut; this answers better than the others, as it is impossible for the sac, when it has once been treated in this way, to fill again; but none of these methods are quite satisfactory. They often succeed, it is true; but, even when the cyst does not return, it is very common for a hard irregular mass to be left behind, interfering with the action of the tendons, and causing an un- sightly tumor. I have known a swelling of this kind persist unaltered for twenty years in spite of continued attempts by kneading- and other measures to g-et rid of it. When it is desired to remove them thoroughly and finally, it answers much better to dissect them out. There is no diffi- culty unless they have been ruptured and squeezed several times before; they separate readily from everything- round except the tendon sheath. Generally they are firmly attached to this, and often when the uniting- band is severed the tendon may be caught sight of, lying in its groove, and showing- that the cyst was in communication with its sheath. If the opera- tion is done carefully, and the hand kept on a splint for a day or two after, the cure is effectual, and the scar can scarcely be seen at the end of a week. If, however, the cyst has been much handled first, particularly if several unsuccessful at- tempts at squeezing it have been made, it must be left for some time before attempting- any such preceding. Compound Ganglion. It is more serious when the dilata- tion involves the sheath itself, especially if it is a large com- pound one, including many tendons, such as that in the palm of the hand, or if it is in the immediate neig-hborhood of a joint. Even where there is only a single tendon, and the size of the sheath is not very great, the inconvenience is often considerable ; but in these cases the character of the wall rarely undergoes much change, and if they are not cured by blistering or tapping they are certain to yield to subcutaneous incision, 150 Sprains ; their Consequences and Treatment. followed by pressure and passive motion. In the larger ones the lining- membrane and the contents have, generally speak- ing, undergone such modifications that it is often impossible to promise more than relief. Like the others, their origin may sometimes be traced to a single strain, though it is more usual for them to develop as a result of repeated injury. In proportion to their number, communications with joints are certainly more frequent; but this, of course, is mainly regulated by anatomical considera- tions, and by the condition of the joints themselves. If these are affected by rheumatic gout, or if cysts develop from them for other reasons, it is all the more likely to occur. Sometimes the connection is due, as I have seen myself, to the enormous size of the ganglion; it grows larger and larger until the structures in between are so thinned by absorption that they give way, but more often, as Morrant Baker has shown, the reverse of this happens, diverticula form along tendon sheaths, or through weak parts in the capsule of joints, and appear perhaps some distance off as cysts which closely resemble ganglions. The fluid in the interior may be identical with that found in the smaller forms, or it may be more liquid and less gelat- inous. It develops in a very short space of time; I have found it present and of typical consistence within three weeks of a strain. The wall is usually much altered in character ; in one instance it was in a condition almost identical with that met with in joints as a result of strumous inflammation, greatly thickened, that is to say, much too vascular, semi-translucent in appearance, and covered over on its inner surface with numerous little granulations. In other cases it is much tougher and firmer, and projects into the interior in great folds and fringes, which lie between the tendons, and seriously interfere with their action. Occasionally, the sheath is divided into chambers, and very often it contains numbers of minute bodies of the same shape and size as melon seeds. What these are formed of is not absolutely certain in all cases ; it seems most probable that, in the majority, they are developed either from the fibrin of extravasated blood, or from lymph that has col- lected in the sheath, and has been worked continually back- ward and forward by the movements of the tendons. When they are present in any number the wall is, as a rule, coated Sprains ; their Consequences and Treatment. 151 over and roughened with material of the same character, so that probably the latter explanation is correct. They contain no cells or fibres ; on the addition of acetic acid they swell up so as to become translucent. All that can be made out is an indistinct concentric marking-, as if they were formed of layer after layer of some fibrinous material. Ganglions such as these must be treated on totally differ- ent principles to the smaller ones. Palliative measures are of little use; free subcutaneous division of the wall has been practiced with success in some of the simpler ones, where there are no melon-seed bodies; and in the case of the great palmar one, section of the ligament that divides it in two has been recommended, but I have had no experience of it. Generally speaking, the sac must be laid open freely, the whole of the fluid removed, together with the melon-seed bodies present, any partitions that exist, dividing the interior into chambers, thoroughly broken down, and even in some instances it is necessary to scrape the wall, so as to clear it from the adherent lymph. Then it must be drained so that it does not refill. Naturally this operation is a very serious one. There is great danger of inflammation setting in, and even if it does not, some permanent degree of rigidity, in spite of the early use of passive motion, is always left behind. If it does, the conse- quences may be disastrous to the very last degree. Cysts that develop in connection with joints, whether as a result of injury or of rheumatic gout, or of both together, must either be left alone or treated in the same way. In this one would be guided mainly by the age and constitution of the patient, the condition of the joint as regards security and movement, and the size and rapidity of formation of the cyst. I have seen them in connection with the shoulder, ankle, and knees; and no doubt they may occur in other joints as well. Sometimes they caused but little inconvenience; at others they spread so rapidly, and attained such a size, that it was absolutely necessa^ to drain them. In nearly all there was a great deal of stiffness afterward, but this was due in part to the original disease; one of them suppurated. nO i T /A 1 " ~ ) 3 J J Q x CHAPTER XII. SPRAINS OF THE BACK AND NECK. SPRAINS of the back and neck are sufficiently common and important to deserve a certain amount of separate considera- tion. The structures concerned are exceedingly complicated; there is an immense number of separate joints of various shape and size, and in addition there is the spinal cord running- in a canal down nearly the whole of its length, and giving- off the nerves which pass out on either side between the bones. JSTor do the injuries themselves vary less in character and severity. In some they are exceedingly slight; in others the consequences are as serious as any that occur in surgery. Some, too, have gained a most unenviable notoriety from their connection with railway accidents; for whatever may be the truth as regards many of these cases, whether they are deceptions or not, there can be no question that sometimes very considerable injuries are produced by the way in which the backbone, and the structures in connection with it, are strained and wrenched when the body is thrown violently backward and forward as it is in collisions. One of the most singular features in connection with these sprains is the way in which the backbone itself, and the mus- cular and ligamentous structures around it, are overlooked and ignored. Even in the ordinary accidents of every-day life there is a great tendency to lay everything that is serious or lasting to the credit of the spinal cord. In railway cases there is no hesitation at all; if any serious result ensues it must be the consequence of damage this structure has sustained, or of inflammation following it; little or no attention is paid to any- thing else. Yet it is difficult to see why the other structures should enjoy immunity. The vertebral column may be strained, especially in the cervical and lumbar regions; the ligaments torn or stretched; the nerves bruised or crushed; the smaller Sprains ; their Conseqtiences and Treatment. 153 joints between the segments twisted and wrenched; the mus- cles detached from their bed and torn across, or thrown into such a state of cramp that they become rigid and unable to act with freedom ; or the fibrous sheath which contains them and helps to secure the bones laid open and filled with blood. Results, in short, of the most serious description are not un- common, and often leave lasting- evidence of their existence be- hind, when the spinal cord itself escapes completely. Injuries of the Spinal Cord. When it is hurt the symp- toms cannot easily be mistaken. There may be insensibility for a time even when the head is not injured. A certain de- gree of shock is always present, and when this has passed off there is paralysis or loss of power, corresponding in extent and degree to the amount of injury sustained. This may make itself apparent at once, or some time, even hours, may elapse before there is any definite evidence of its presence. Sometimes it is so slight that it can only be detected by the most careful investigation; at others it is so severe as to give rise to the suspicion of fracture or dislocation. Geiieralh r speaking, when it is due to bruising, or to what is still more common, effusion of blood into the tissues round the cord so as to compress it, the S3 r mptoms begin to diminish at the end of a few days. Recovery may then progress without interruption until it is complete, or it may be arrested at any point, leav- ing behind it greater or less impairment of power. Sensibility is frequently affected, too, but it rarely suffers in anything like the same degree. If it is lost completely the prognosis must be regarded as exceedingly grave, for it nearly always indi- cates that at some one point the cord has been crushed and disorganized. Sometimes a certain amount of hyperaesthesia or increased sensitiveness of skin may be detected over a small area immediately above the seat of injury, but the general tenderness all down the spine, which is such a common symp- tom in sprains of the back, whether they occur in railroad ac- cidents or elsewhere, and the strange sensations, such as crawling, creeping, or tingling, experienced in the limbs, are probably due entirely to other causes. They are certainly met with in cases in which there is no reasonable ground for suspicion that the cord itself has been hurt in any way. Into this part of the question, however, it is not my inten- tion to enter at present. Injuries of the spinal cord, and the 1 54 Sprains ; their Consequences and Treatment, consequences that may result from them, are matters much too serious to be regarded merely as complications of sprains of the back, and the subject has been already exhaustively treated by Page in his work on " Injuries of the Spine and Spinal Cord." My contention merely is that a very large number of the symptoms which are usually considered as definite proof that the spinal cord has been hurt may be, and in a large proportion of instances probably are, due altogether to the injuries that the other structures in the back must sus- tain in such accidents. Injury to the Muscles and Ligaments; Sprains. S. C., thirty-two years of age, a strong, healthy man of exceptionally good physique, in getting out of a barge slipped and pitched head-foremost into the hold among some bales of goods. The shock was in a measure checked by his hands, or he would almost inevitably have broken his neck. As it was, he lay for some moments unable to extricate himself, with his head doubled under him and his chin driven down upon his chest. He did not lose consciousness; there was no concussion or other injury to his brain; there was no fracture or dislocation anywhere about his spine, though, owing to the severity of the shock he had sustained, he was unable to stand upright, and it was almost certain that his spinal cord had not suffered any very serious hurt, for after he had recovered from the shock he was able to move his arms and legs about freely in all directions. Sensation was not in the least impaired ; there was no tingling or feeling of pins" and needles; nor was there that peculiar sense of constriction round the body as if a string were tied round it, of which so many patients complain. The stress had fallen almost entirely on the muscles and ligaments at the back of the neck ; these, no doubt, were severely strained, and it seems probable from what followed that the nerves running from the spinal cord had suffered in the same way. The next day the shock had completely passed off. He had slept but little during the night, and he still felt giddy, everything seeming to go round when he attempted to sit up- right; but he had recovered his natural color and expression, and the pulse and temperature were perfectly normal. He had completely lost, however, the power of moving his head or neck; the least attempt, especially nodding, brought on severe attacks of pain, shooting up over his head and behind Sprains; their Consequences and Treatment. i$5 his ears on each side, so that he sat either with his chin rest- ing- on his hand, or with his thumbs behind his ears and his fingers grasping- his face. Indeed, without support of some kind he seemed unable to hold his head upright. He com- plained of his back and neck feeling weak, as if he were going to be paralyzed, mistaking, as Hood has pointed out, the fear of movement due to the pain it causes for actual loss of power. The skin was exceedingly tender to the touch, as it is over every sprained joint, and there was a certain degree of swell- ing, very ill-defined in outline, over the part that had been most severely strained. What caused him most apprehension, however, was the difficulty that he felt in opening his mouth. He could shut it easily enough, but slight as is the muscular effort required to move it in the opposite direction, it was almost too much for him. The muscles which act from the upper part of the chest, and help to form a fixed point from which the lower jaw can work, were unable to do their fair share. They had not been injured themselves, but the nerves supplying them had been strained in the neck at the moment of the fall, and were unable to carry the necessary stimuli. For the same reason his breathing was very shallow and his speech slow and deliberate. In a few days this began to pass away ; the sense of strength returned, and movement became much more easy; but for a long time a peculiar sensation could be detected in the neck when the head was turned from side to side, as if two rough- ened surfaces were being rubbed against each other, or some dense fluid, such as extra vasated blood, were being squeezed to and fro in the meshes of the cellular tissue. Gradually this, too, disappeared, but in spite of repeated blistering, the stiff- ness still persisted in the back of his neck. Improvement w r ent on fairly rapidly up to a certain point, but then came to a standstill. Forcible manipulation, however, assisted by thor- ough kneading, soon effected a cure. In this case the mischief was well defined, the ultimate re- covery, though it was delayed for some time, was complete, and there was no inflammation or other complication. The cord itself was not injured, though just at first there was rea- sonable ground for suspicion ; the whole of the symptoms were due to the damage the muscles and ligaments had sustained, and to the way in which the nerves were stretched. 156 Sprains ; their Consequences and Treatment. In all probability, as Page has pointed out, many of the cases of what is sometimes called railway spine may be ac- counted for in this way. The sjanptoms, because the}^ are serious and persistent, are referred to the spinal cord, instead of to the structures which surrounded and are especially in- tended to protect it. Paralysis is one of these. Where this really exists there can be no question that the spinal cord, or the nerves at their exit from it, have sustained some exceedingly grave hurt. It may be that curious, almost indefinable, effect known, for want of a better term, as shock to the nervous system ; or it may be actual bruising and laceration ; something of the kind there must be, and in such a case it is necessary to exercise the most extreme precaution in the question of prognosis. But it often happens that, without the least intention of deceiving, patients describe themselves as paralyzed, or unable to perform some particular action, when, as a matter of fact, the attempt is merely prevented by pain, or, what is still more singular, by the belief that they cannot. Hood has pointed out how pa- tients often describe a joint as feeling weak, speaking of it as if it were in need of some mechanical support, when the real cause is the dread of calling into action muscles that are stiff- ened from disuse or rheumatism. So it is with the spine ; after a severe strain there is a certain amount of difficulty about calling the muscles into play, just as there is when they are affected by lumbago, and the patient is naturally very apt to think that he has lost power over them, and is going to be paralyzed. This was the case in the instance that I have quoted above, and similar examples affecting different parts of the body, according to the seat of injury, are of exceedingly common occurrence. Hypersesthesia, again, or increased sensitiveness of the skin, is always regarded with great apprehension. In some par- ticular cases, as I have mentioned already, it is true that it is a symptom of injury to the spinal cord ; but in the great ma- jority, especially in those in which it extends down the whole of the spinal column, it occurs for exactly the same reason that it does over any sprained ligament, or muscle, and means nothing more. The crawling sensations, too, that are complained of in various parts of the body, the tingling, and pins and needles, Sprains ; their Consequences and Treatment. 157 are still more ambiguous. Often they are due to causes of an entirely different nature, pressure or traction, for example, on some of the nerves, or some alteration in the amount of blood flowing through the part; they cannot, at least in the absence of other evidence, be regarded as proof that the spinal cord has suffered to the exclusion of everything else. Occasionally even more remarkable symptoms are met with. In one case under my own observation, where the patient sustained a very severe strain with some contusion in the lower part of the dorsal region, there were typical attacks of what are known as lightning pains, shooting round the body with great in- tensity, and then ceasing abruptly; yet there was no evidence at any time that the injury had involved the spinal cord itself. In short, these symptoms, which are usually regarded as definite proof that the cord has been injured, so far as they prove anything, are rather suggestive of injury to the struct- ures that lie round it and protect it. These must sustain the brunt of the violence in any accident; the cord itself is placed in the position of the greatest possible security, protected as far as it can be from any external hurt, so that in the vast majority of instances it (very fortunately) escapes. From its great importance, and from the disastrous results when it is injured, it has caused everything else to be overlooked and forgotten. Injury to the Bones. Of the frequency with which the bones are affected there can be little doubt. Injuries of the back, in the shape of blows or strains, have to account for a very large proportion of cases of disease of the spine; and, probably, if the history of the rest could be obtained, it would be found to be true of most of these. It is difficult, of course, to bring forward direct proof of this; but a certain amount of confirmation may be obtained from the locality in which this affection is most common. A blow may affect any part; but strains, in such a structure as the vertebral column, are always felt most severely where a rigid and a flexible segment are joined together where, for example, the neck or the lumbar region joins the thorax, which, from the attachment of the ribs and for other reasons, is peculiarly stiff. At any rate, whether this is the explanation or not, it is a fact that disease of the spine is particularly common at these two spots. Injury to the Smaller Joints. Sometimes the strain falls 158 Sprains ; their- Consequences and Treatment. on the smaller joints between the vertebrae, though it must be admitted that it is rarely possible to find any direct evidence of their being hurt. There are so many of them ; they lie so close to each other; and the amount of movement possessed by each is so slight that unless the injury is extremely local- ized its effect is spread too widely to strain any single one. It is not improbable, however, that they suffer more often than is generally suspected; only the injury, owing to the depth at which they lie, and the way in which they are covered in by muscles, is not correctly diagnosed. At least, evidence of past mischief is sometimes found post-mortem, long after all histor3 T is forgotten ; and suppuration even has been known to occur, and to spread until it made its way into the spinal canal, and involved the cord itself. Ligaments. The structures, however, which bear the brunt of strains, are the bands of fibrous tissue, and the mus- cles on the back and on either side of the vertebral column. With regard to these, the part played by the former is entirely mechanical. Close under the surface there is a broad sheet of extraordinary strength, extending outward over the muscles, binding them down, and protecting them so far as it can from being overstretched. A little deeper it is much more delicate and vascular, forming sheaths for all the separate slips, and uniting them closely to each other. Deeper still it becomes strong again ; but here the fibres are short and irregular in direction, running between the prominences with which the bones are covered, and acting the part of ligaments. This fibrous tissue cannot stretch. When the violence is so great that the muscles are overcome, or so sudden that they are caught unawares, it resists as long as it can ; then it gives way, rarely at any one single spot; more often here and there, where it is attached to the bones, or becomes continuous with the muscles. Muscles. These, on the other hand, are the most active ligaments the back possesses. Not only do they move one bone upon another, but, within certain limits, they are the main agents by which the extent of the movement is regulated. When those limits are passed, and, as a rule, not till then, the purely passive fibrous bands are called into play. The result of this is that, as a rule, in accidents of this kind, the muscles suffer to a very serious extent. Sometimes they Sprains ; their Consequences and Treatment. 159 are overstretched, and lose their power of contracting again ; or they are seized with cramp; or they are crushed together and bruised. Sometimes there is a great effusion of blood into their substance, so that they become swollen and painful; or the sheath of fascia which surrounds them is split open to such a degree that they are displaced entirely from their surround- ings, and dislocated ; or they are even torn in two or wrenched from their attachments. Dislocation of Muscles. Many of these injuries occur commonly in sprains of other joints, but one of them, disloca- tion, is, if not confined to the back, at least very rarely met with elsewhere. It is most common in the neck, for here the movements are very rapid and extensive, while the muscles are especially long and slender. The head is suddenly twisted round to look in some awkward direction; there is a sudden sharp stab of pain, often causing the patient to cry out ; some- thing appears to be caught, and the head is held fixed. In a minute or two, when the acute pain has subsided, it can gen- erally be brought nearly straight again; but it requires con- siderable effort, and it cannot be turned so as to face in the opposite direction, or even kept straight for long. As soon as it is allowed to assume the position of least discomfort, it bends over once more to the affected side. Careful examination in these cases sometimes shows a tender spot on the contracted side, slightly too prominent. If this corresponds in position and direction to some muscular slips, and if, when the part is manipulated, the swelling disappears, and full and painless mobility is instantaneously restored, it can hardly be doubted that the symptoms were due to the dislocation of one of these, which has slipped back into its place again. In some cases an audible snap can be heard by the patient at the moment of reduction; and, in one under my own care, an incautious move- ment on the part of the patient, before repair was complete, reproduced the displacement. I have known several instances in which, from the prac- tically instantaneous character of the relief, it is almost certain that this had happened; but I must admit it is much more common for the swelling to disappear gradually and for vol- untary power to return by slow degrees. Probably, in these instances, there is no real dislocation ; the muscular fibres are either in a state of painful and spasmodic contraction, such as is 160 Sprains ; their Consequences and Treatment. common in the leg after unusual exertion, or some of them have been torn and strained, so that movement is painful until the injury is repaired, and the extra vasated blood absorbed again. I have never met with any similar unmistakable disloca- tion in the loins, though, no doubt, from the description given by Callender, its occurrence is quite possible. The patient, he narrates, was carrying a heavy weight on his shoulders, when he suddenly slipped, and, in spite of all he could do, was swung round by the momentum. The pain for the moment was in- tense, and though it did not continue his back remained stiff, so that he could not move about with proper freedom. On examining the part there was one very tender spot in the muscles by the side of the spine, where a decided irregularity could be detected; this was diagnosed as a dislocation. The patient was instructed to repeat, so far as he could, the move- ments he went through as he fell; and while doing this firm pressure was made on the painful spot. The swelling disap- peared at once; full power of movement was regained; and the sensation of stiffness completely vanished. The case was com- pleted, and the diagnosis verified by a subsequent repetition of the accident. Method of Reduction. In any injury of this description, even if the presence of a dislocation is not certain, it is always worth while to carry out some simple manipulation such as that described above. Whatever may be the reason, whether it relaxes spasm, or whatever it does, it is a fact that almost immediate relief is sometimes gained by this, though the symp- toms are not in the least characteristic. In one case under my own care there was no history of an accident at all. The pa- tient was a young man, healthy enough himself, but of rheu- matic and gouty parentage. He had been sitting incautiously in a draught when overheated, and got an attack of muscular rheumatism. Curiously enough, however, the pain was limited to one side, and almost to one spot; had he met with an acci- dent, I should at once have suspected the existence of a strain. In spite of the history, however, I determined to try the effect of sudden vigorous contraction, and accordingly made him sit down on a low seat, with his feet firmly pressed against the wall in front, so that the pelvis should be securely fixed. The tender spot was carefully marked, and then it was explained to him that he must stoop forward as low as possible, and at Sprains; their Consequences and Treatment. 161 the word of command suddenly straighten himself up. One arm was placed under his chest to assist him in this, and the thumb of the other hand firmly pressed upon the tender spot. The patient carried his part out loyally, in spite of the pain, and was completely and thoroughly cured at the second at- tempt. Some pain and stiffness returned in the course of the next day, but determined extension and contraction of the muscles involved, relieved him without further assistance. It is very important in accidents of this kind to get a per- fectly accurate account of the way in which it happened, and the smallest details often prove of great importance. The chief difficulty is to determine whether the seat of injury is one of the smaller joints, or a muscular slip by the side of it. Sometimes a soft and rather indefinite swelling can be made out beneath the skin; more often there is merely a certain amount of local tenderness, with a sensation of stiffness, or of inability to execute some particular movement, amounting in some cases, as has been already mentioned, even to a suspicion of paralysis in the patient's mind. Bruising is rarely seen, owing to the depth at which the injured part lies. If the situation corresponds fairly well with the position and direction of some slender slip of muscle, the assistance of the patient must be called in, and what is required of him thoroughly explained. There are two chief ways in which the reduction may be effected; sometimes one succeeds, sometimes the other. In the first the patient is placed in an attitude that relaxes the injured part as much as possible, and then, while the hand or finger is firmly pressed upon it, is made to bring it suddenly and vigorously into action. In the second, which is rather the better for it is very difficult at once, and when suffering pain, to move the back or neck quickly in any given direction at a moment's notice the body is placed so that the dislocated slip is put upon the stretch, and held in that po- sition by the operator, while the patient endeavors to straighten himself up against the resistance. The muscle suddenly con- tracts, alters its shape and consistence, and, from the relief that is experienced afterward, must, apparently, slip back again into its bed. Sometimes there is a sharp feeling of pain at the moment, and the preliminary stretching is always disagree- able, but the use of an anaesthetic is, of course, impossible. Muscular Pain. The most common trouble, however, after 1 62 Sprains ; their Consequences and Treatment. sprains is something- different to this, and is probably closely allied to muscular rheumatism. It may be the result of un- usually severe, or of unusually prolonged effort; nothing- is felt at the time, or for a few hours; then, g-enerally speaking, at night a peculiar aching sensation begins to make itself felt. The skin is often tender to the touch, especially over the points that correspond to the exit through the fascia of the cutaneous nerves ; but there is no heat or redness. The tissues show no sign of bruising ; steady pressure, though it is unpleasant at first, gives relief rather than causes pain ; and, except as a re- sult of disturbed rest and sleep, there is no fever or constitu- tional disturbance. There is merely a constant wearing pain, with a sensation of stiffness and want of power, that renders rest for any length of time impossible, and entirely prevents the patient holding himself upright or moving about with freedom. What may be the actual nature of the change in the tissues is uncertain in many of these cases. In some, no doubt, there is rupture, or straining of the muscular fibres, or there are minute haemorrhages; but from the practical identity of the symptoms with those of myalgia, due to cold or gout, it seems probable that the cause is to be sought in the changed condi- tion of the circulation, or of the nutrition of the part. During contraction of the muscles a much larger amount of blood flows through them than when they are at rest, and the blood- vessels are very much dilated. It is possible that when this is carried to excess by prolonged overwork it is succeeded by a condition of passive congestion, the vessels being overloaded, and the blood unable to circulate as freely or as rapidly as it should. Then the waste products accumulate and act as sources of irritation, and fresh material to replace that which is exhausted by fatigue is not supplied in sufficient quantity. Probably in those who are young and healthy this is not of material consequence; it merely causes a certain amount of muscular stiffness, which soon subsides when the part is rested and the natural equilibrium once more restored; but if any constitutional taint, such as gout or rheumatism, is present too, it seems to stamp the complaint with its own peculiar character, and makes it tenfold more severe. The most common situation for this to occur is in the loins, owing to the large masses of muscle situated there, and to the Sprains; their Consequences and Treatment. 163 way in which they are called upon for unusual or sudden ex- ertion m lifting 1 heavy weights; but it may occur anywhere, even in the extremities. Wherever it is, care must be taken not to confound it with other disorders. It is not uncommon for affections, even of such distant parts as the viscera, to be attended by pain in various regions of the spine. To say noth- ing of examples which must occur to every one, I have known the back-pain of incipient small-pox treated as lumbago, and massage has before now been vigorously applied to a case of stone in the kidney. General Treatment. In the milder cases merely local treatment may suffice, but it is so common for an outbreak of some complaint (the existence of which may hitherto not have been suspected) to follow strains, that practically in all general treatment adapted to the particular constitution of each patient is essential. Just as an injury to the foot is often the apparent cause of the first attack of gout, so many of the muscular strains of the back owe at any rate their persistent character to the presence of some similar complication. It is for this reason that careful attention to diet is so necessary ; and that such drugs as colchicum, iodide of potash, chloride of ammonia, the carbonates of the alkalies, and others prove so useful. Only it rarely happens that any indication as to which of these internal remedies is likely to prove most bene- ficial can be derived from the condition of the back itself. This is only to be ascertained by carefully inquiring into the previous history of the patient, and thoroughly investigating the other symptoms that are present. In other words, local measures should be employed to relieve the pain and stiffness, and to restore the condition of the muscles as soon as possible; but it must not be forgotten that the general state of the pa- tient in most instances needs quite as much attention. Local Measures. Warmth. Warmth, either applied to the part itself, or generally over the whole surface of the body, is of excellent service in relieving the consequences of strains. The simplest plan is to wring a piece of flannel out of water as hot as can be borne, or to roast it in front of a fire, and press it firmly upon the affected area, renewing it from time to time as it cools. The skin becomes red; more blood circulates through it, and probably a considerable amount is diverted from the deeper parts; the congestion is relieved for the time 164 Sprains ; their Consequences and Treatment. being-; the waste products are carried away; more nutritive material is supplied, and the stiffness certainly diminishes. Or bags of hot sand, or salt, may be used ; they retain the heat considerably longer, and from the way in which they can be fitted into any irregularity of surface, are particularly suited to certain parts of the body. If this is not convenient, the electric brush may be tried, passing- it regularly all over the surface of the skin after it has been thoroughly dried first to increase the resistance. It is probable that the benefit derived from this is due almost entirely to the influence it possesses on the blood-vessels, and not in any way to the chemical effects of the current. Baths. Hot-water or vapor baths are almost too well known to require mention. Turkish ones also enjoy a great reputation, especially for recent cases, and among those who are accustomed to them. For others, they must be recom- mended with a certain amount of caution, and the subsequent treatment in any case requires much more attention than it usually receives. At Aix, when the full effect is desired, the patient, after his bath, is quickly dried, wrapped in blankets, and carried in a sedan chair to his hotel. As soon as he reaches his apartment he is lifted into bed, still swathed like a mummy, covered up with additional blankets and a quilt, and left to perspire for a longer or shorter period. After twenty minutes or half an hour he is carefully rubbed down by an attendant who had accompanied him from the bath. Where this is im- practicable, the patient should at least be very careful not to hurry away, but to remain two or three hours if necessary, and above all, to make sure that he is properly covered up. When the complaint has already lasted some time, douche baths may be employed, conjointly with vapor baths. The patient should be seated on a wooden stool, with the feet im- mersed in warm water so as to avoid chill, and then jets may be directed against his back in any required direction. The size of the jet must be regulated by the amount of pressure, and by the temperature of the water; but it is rarely advisable for it to be more than a quarter of an inch in diameter, and it is always best to begin with warm water, and gradually re- place it by cold. The effect is greatly enhanced by massage afterward. Those w r ho have never tried these baths, or who suffer Sprains ; their Consequences and Treatment. 165 either from giddiness and a feeling 1 of fullness in the head, or from a sensation of faintness after their use, may be recom- mended to take local ones with perfect safetj'. If the patient is in bed, a cradle may be placed over the body so as to leave a space round him, beneath the bedclothes, and the steam of a kettle introduced by means of properly-arranged tubing, until the desired effect is produced, taking care not to scald the patient's legs. Where he can sit on a chair, it is more convenient to arrange a mackintosh, or, if this is not available, a blanket, round his neck, so as to reach the floor on all sides, and then to place under the seat of a chair a spirit lamp with some boiling water. Both these methods insure copious per- spiration within a very few minutes, and possess the great advantage of not affecting the patient's head or interfering with his respiration. Further, there is less risk of catching cold afterward, and aggravating or reproducing the original trouble ; if the bath is taken of an evening, the patient can be placed in bed at once, and nearly always can make sure of some hours' refreshing sleep. At Aix-les-Bains, according to Dr. Stewart, the method is still more highly elaborated. When the patient is sent to have a steam bath (the Berthollet, as it is termed), he is directed to an apartment which contains a curious wooden box, with a round hole in the movable lid. After undressing, he steps into the box^ and finds that he is shut in all but the head, the round hole being occupied by his neck. Immediately a valve on the level of the floor is opened, the hot vapor rises about him, and he soon begins to perspire freely. The per- spiration running down his brow trickles from his face. Pres- ently he feels the streams flow down his sides and legs, and very speedily a feeling of oppression and debility comes on. After ten or twenty minutes the bath is opened up, the patient carefully dried, and removed to his hotel. Hot-water baths act in the same way. The beneficial effect they exercise is almost entirely due to their temperature, and proportionate, within limits, to the length of application. The salts that they contain, whether neutral, alkaline, or sul- phuretted, are of very little consequence. If they exist in cer- tain degrees of concentration, they stimulate the cutaneous circulation, but that is all. For this reason peat or mud baths are, as a rule, more efficacious. The one feature common to 1 66 Sprains ; their Consequences and Treatment. all bathing- establishments which enjoy a high repute is the temperature of the water, and probably the benefit derived from the use of the baths (as distinguished from a sojourn at the place) is due entirely to this. Friction, Friction, either with the hand or with a flesh brush, is very grateful in these cases. The direction should be upward, toward the head, and the strokes light and rapid. The effect is, to a certain extent, the same as that of heat ; there is a temporary contraction of the vessels near the sur- face, followed by a more lasting dilatation and more rapid circu- lation of the blood. It possesses, however, in addition, con- siderable influence on the nerves of sensation, and it is not improbable that it is felt even more widely than this would imply. At least, it is difficult to explain on other grounds the undoubted power which steady friction along the back seems to possess in allaying some forms of nervous excitement and inducing sleep. Liniments. Stimulating liniments, containing camphor, ammonia, or turpentine, may be usefully employed in conjunc- tion with either friction or heat. Sprinkling a few drops of turpentine on the heated flannel before applying it is gener- ally sufficient, or some of the liniment may be rubbed in with the hand. This acts as a mild form of counter-irritant, prob- ably temporarily withdrawing the blood from the deeper parts toward the surface, and where the stiffness and pain have lasted some time this is more effectual than either heat or fric- tion by itself. If the tenderness is limited to one or two spots, and especially if these correspond to the places where the nerves perforate the fascia, blistering fluid, painted on once or twice, according to the thickness of the skin, answers better still. In rare and exceptional cases more powerful applications, even the actual cautery, may be used. How these act is not clear; they may merely withdraw blood from the deeper parts or they may act in some way through the nervous system; for there is little doubt that certain organs are always in definite nervous relation with certain parts of the surface of the body, and are affected when these are in any way stimu- lated. However this may be, there is no question that some- times this agent may be employed in relieving deep-seated pain, especially about the bones, with conspicuous success. Sprains ; their Consequences and Treatment. 167 When the skin feels sore and tender after a sprain, the essential or aromatic oils often give very great relief. Many of the quack remedies employed to soothe pain, even the deep- seated pain of acute gout, owe what merit they possess almost entirely to these. A very favorite application in Germany, known as Hoffmann's balsam of life, consists of an alcoholic solution of balsam of Peru and seven of these aromatic oils mingled together. They may be either painted on the skin, and left exposed, or dissolved in spirit in various proportions, and covered over with oiled silk to prevent too rapid evapora- tion. Menthol is one of the most convenient, and acts especi- ally well when mixed w T ith camphor or croton-chloral, so as to form a thick oily liquid. Probably in this instance, too, the relief is in no small measure due to the effect produced upon the cutaneous nerves. In certain cases minute quantities of morphia, belladonna, or veratria may be combined with these. It must, however, be remembered that if chloroform is used as a solvent, a con- siderable amount is absorbed through the skin, particularly if friction is used at the same time, and that in spite of the comparative thickness of the cutaneous covering of the back and the paucity of sebaceous glands. Belladonna plasters, which are strongly recommended by some, not only share with all other plasters the objection of being intolerably dirty, but have the additional disadvantage of sometimes causing an acute attack of eczema. Quite as great benefit may be derived by wearing a belt of flannel or, if this is too irritat- ing, one of silk next the skin. The hypodermic injection of anodynes, such as morphia, may occasionally be necessary, but it is always as well to postpone this until all other remedies have been exhausted. The very ease with which it gets rid of the pain is its greatest danger. It rarely cures the complaint, though it gives a tem- porary sensation of comfort, and is only too likely to be re- quired again before many hours are past. Ironing. Besides these there are other remedies which are especially suited to deep-seated and large muscular masses, such as exist on either side of the spine in the loins. Ironing has already been alluded to. The patient should lie in bed, rather on his face, with the body supported by pillows in as comfortable a position as possible, and should turn from side 1 68 Sprains ; their Consequences and Treatment. to side as occasion requires. A well-warmed piece of flannel (great stress is laid by some on its being- unwashed) is then stretched over the affected part, and the muscles on either side of the backbone thoroughly ironed in all directions with an iron as hot as can conveniently be borne, using consider- able pressure at the same time. The best for this purpose are those of rather small size, with the edges and angles well rounded off, so that they may be pressed into all the depres- sions between the bones without causing pain. Acupuncture. Acupuncture, ag-ain, though it is rarely em- ployed nowadays, and seems, like bleeding-, to have gone out of fashion, is at times very efficient in removing chronic muscu- lar pain. How it acts is not thoroughly explained. Ordinary long- darning needles answer very well. They are simply thrust through the skin, deep into the muscles, and withdrawn again after a few minutes. If the plan is successful they leave behind a bright red areola, which varies considerably in size and duration in different cases, and probably is dependent on the condition of the nerves that are stimulated. The pain is exceedingly slight, especially if the thrusts are made firmly and rapidly, and the punctures scarcely bleed. Galvanism. Galvanism, too, is very successful in treating- muscular stiffness. The skin should be well sponged over first with warm salt and water, so as to avoid irritation as much as possible, and either the labile or the stabile plan adopted. The latter is the best to commence with, and then, after the cur- rent has been passing some time, the direction may be reversed once or twice. The electrode applied over the muscle should be of larg-e size (a zinc plate covered over with leather, well moistened, answers as well as anything-, as it may be cut or bent to any shape), and the current used of proportionate strength. Then, before leaving- off, a smaller electrode may be substituted, and passed over the whole of the surface with a weaker current (if possible in an ascending' direction) so as to secure its refreshing action and remove any sensation of fatigue. The sittings should not last long-er than five or ten minutes, and it will generally be found that every other day is sufficient, especially if kneading- or ironing- is used on the alternate ones. Massage. Massage, if it is thoroughly carried out, is more successful still. Its action is most refreshing and invigorating. Sprains ; their Consequences and Treatment. 169 Under its influence the aching- and stiffness disappear, the blood circulates more freely through the muscles, the waste products are carried away, nutrition improves, and strength and voluntary power beg-in to return at once. It seems to possess the same restorative influence over the deeper struct- ures that friction has upon the skin. Percussion and kneading are both recommended. The for- mer is the easier, and does not require so much skill or ex- perience ; but it only affects superficial parts, and is altogether of more limited application. The ulnar side of the hand may be used, or an instrument which bears a general resemblance to a hammer, with a stem of whalebone to secure elasticity, and a head faced with India-rubber. With this, held rather lightly, the whole of the stiff and painful part of the back is thoroughly percussed, the number of strokes rising to as many as three or four hundred in the minute, until the skin begins to glow. Kneading is of much greater service, but requires practice before the full benefit can be obtained. The object is to com- press and relax alternately the deeper-lying muscles, and to squeeze their contents onward, so as to insure a more rapid flow of blood and plasma through their substance. Conse- quently the movement must be regular, definite in direction, and well ordered. A muscle at rest receives an exceedingly small quantity of blood, compared to what flows through it when it is con- tracting. So long as it is doing no work, the plasma which pours through the walls of the vessels into the interspaces round remains almost stagnant; the fibres are very slow in getting rid of their waste and in receiving a fresh supply. As soon as the muscle begins to act, the vessels dilate, the current of blood is quickened, the plasma is driven on at a much faster rate, and the nutrition improves beyond all measure This is helped to no slight extent by the alteration in the shape of the muscles. These are all incased in a comparatively unyielding fibrous sheath, differing in strength and density in different places. The plasma collects underneath this, filling up all the clefts and spaces left between the fibres. Each time the muscle contracts it compresses some of these, and causes others to dilate, so that it alternately sucks and drives the fluid plasma on. And, as a matter of fact, it is well known that the flow 170 Sprains ; their Consequences and Treatment. of plasma, as well as that of blood, through the substance of a muscle, increases immensely as soon as it begins to work. Massage aims at imitating this. Its object is, by the roll- ing and kneading of the muscles, to increase the flow of blood and plasma through them, get rid of the accumulated waste, and stimulate nutrition by supplying fresh material in larger quantity. If carried out thoroughly it is almost certain to give relief, but it is not a thing to be undertaken rashly, with- out previous training, and without some knowledge of anatomy. Massage and rubbing are not synonymous terms. Supposing the lumbar region to be affected, the patient must be placed upon a couch of convenient height as already described in speaking of ironing and well supported from un- derneath by cushions, so that the muscles of the loin may stand out beneath the skin without being contracted. The operator should stand over him, at a suitable distance, so that his movements are not cramped; and then, with both hands, moving one after the other, knead and squeeze the muscles, first on one side and then on the other, rolling them, as it were, away from the middle line, and pressing them onward and upward toward the head. The whole hand must be used, the fingers, as it were, being insinuated, as far as possible, under and between the groups of muscle, the skin being allowed to glide, to a certain extent, over the structures beneath. Then, if there is any very painful spot left, the muscles may be grasped with the hands and firmly kneaded with the thumbs, moving them round and round in small circles intersecting each other over it so as to knead and squeeze the structures round it from all sides. The pressure should be gentle at first, and then gradually become firmer and firmer. No liniment or oily substance can be used, as it weakens the grasp of the hands and tends to defeat the object of the manipulation. If it is desired it may be rubbed in afterward. The rate of movement must vary with the thickness and depth of the tissues to be manipulated, and with the amount of pressure used. Within reasonable limits, the slower the better. There is a great tendency on the part of many, who are supposed to practice massage, to use much too much force, and to make all the movements too rapid. Five minutes, as a rule, is sufficient for a sitting, though it is often beneficial to apply an ascending constant Sprains ; their Consequences and Treatment. 171 current to the muscles for a minute or two more afterward. It answers better to repeat the manipulation later on in the day than to continue too long at one time. The golden rule is never to fatigue the patient, or to produce the least degree of tenderness or bruising. Those who have not had much ex- perience or a thorough training are very apt to overdo it. CHAPTER XIII. INTERNAL DERANGEMENT OF THE KNEE. THE knee joint is occasionally the seat of a peculiar kind of accident, which, for want of a better name, was called internal derangement by Hey, who first described it. It is extremely painful; it occurs during perfect health from most trivial causes; if it happens once it is always liable to occur again; and after a time the joint is very likely to become seriously crippled. Yet, mainly owing to the fact that opportunities of examining the interior of the joint are seldom met with, its pathology is almost as much a matter of discussion as ever it was. It is undoubtedly connected with two flattened structures in the joint known as the semilunar cartilages. Roughly speaking, they form two circles, lying side by side between the bones. The margin of each is the thickest part; from this they slope off gradually toward the centre, where there is a perforation. The circumference, especially that of the internal one, is attached to the bone more or less firmly all round ; but the part corresponding to the centre of the joint, where the two cartilages touch each other, is much the most secure. At this point each of them is interrupted for a short distance, and the four ends so formed are firmly united to the bone beneath. The outer cartilage forms nearly a complete circle, so that its ends lie close together; the inner, on the other hand, barely forms two-thirds of one. This peculiarity of shape, and the presence of several accessory bands, tend to make the inner of the two the more secure. It scarcely moves at all in ordi- nary actions of the joint, merely, when the weight falls on it, expanding a little in all directions from its centre. The outer one, on the other hand, glides backward and forward freely. It is generally supposed that in a typical case of internal derangement one or the other of these cartilages slips from its position and is caught between the bones. As a conse- Sprains ; their Consequences and Treatment. 173 quence the movement of the joint is abruptly checked; com- plete extension becomes impossible; the two bones are forcibly wedged apart from each other, and the ligaments that hold them together are stretched and strained. The internal, in spite of its greater security, suffers more often; the external, perhaps from the very way in which it can accommodate itself, nearly always escapes. Rupture of the Semilunar Cartilages. Sometimes they are torn completely away from their attachments. Godlee mentions one instance in which the external was found rolled up toward the centre of the joint, having been separated from the bone all around the margin. Annandale has described the anterior end of the internal one, stretched or wrenched away from the bone; and probably they may be injured in other ways as well, torn across, for example, or twisted round in various fashions, or, if the violence is sufficiently severe, forced out from the joint altogether until they project beneath the skin. Then there is, generally speaking, laceration of the lateral or of the internal ligaments of the joint as well, so that the bones are dislocated from each other. If the joint is the seat of chronic synovitis, or is subject to attacks of rheumatic gout, or if, in younger people, there is that peculiar loosened condition of the ligaments which I have already described, the displacement may be much more com- plicated. It is not unusual to find in these circumstances that the cartilages may be made to slip backward and forward between the bones by the mere pressure of the finger. It is not fair, however, to regard these as genuine examples of in- ternal derangement. In this, the joint is, to all appearance, perfectly sound and healthy; the violence is exceedingly slight ; and the relief is instantaneous. There may be a tran- sient effusion into the cavity of the joint after the displace- ment has taken place, but clearly there can be no tearing or even severe bruising of any of the internal structures. The greatest injury must fall short of this, or the time required for repair would naturally be much longer. Displacement Without Rupture. The best description is given by Knott, of Dublin, who has suffered from it himself on repeated occasions. It first occurred to him when he was a boy, as he was walking quietly along. All of a sudden, without having sustained any wrench or twist of which he was 1/4 Sprains; their Consequences and Treatment. conscious, he was seized with such agonizing 1 pain on the inner side of the knee joint that he half fell, half sat down, on the ground, sick and faint, with a sensation of utter helplessness. The knee was slightly flexed ; he could not move it one way or the other, and voluntary power over it was entirely lost. In- stinctively he applied his hands one on either side of the joint, and made as powerful a pressure as he could in the hope of relieving the suffering. This caused the flexion to diminish ; when suddenly the pain again became almost intolerable, a clicking sensation was conveyed to his hand and his ear at the same time, and perfect relief came at once. He managed to walk away, and no after trouble of any kind followed. After that the accident happened to him on many occa- sions; he noticed that it never occurred during active move- ment, but only when the muscles were off their guard; and that if the knee-joint was slightly bent, the least force applied so as to turn the toes outward was sufficient to cause it. So long as he walked with the toes turned in the joint felt secure; the reverse of this is the case when the displacement concerns the external of the two cartilages. From this he is convinced that, at least in his own case, the displacement consists in the posterior part of the internal cartilage gliding forward from its position until it is caught between the bones. This forces them apart, like a wedge, and completely stops the movement of the joint. The muscles round contract at once, and become perfectly rigid, so that voluntary action is out of the question for the time. After- ward, when they are tired out, and the joint fills with fluid, the power of movement returns again; but complete exten- sion is not possible so long as the displacement lasts. Hey's account is closely similar. He describes the knee as being not unf requently affected with an internal derangement of its component parts, as a consequence of trifling accidents, and states that the trouble is now and then removed as sud- denly as it is produced, by the natural movement of the joint, without surgical assistance of any kind; but that it may re- main for weeks or months, and then become a serious misfor- tune, as it causes a considerable degree of lameness. " The disorder may happen with or without contusion. In the former the symptoms are equivocal, until the effects of the contusion are removed. When no contusion has happened, Sprains ; their Consequences and Treatment. 175 or when the effects of it are removed, the joint, with respect to its shape, appears uninjured. If there is anj T difference from its usual appearance, it is that the ligament of the patella ap- pears more relaxed than in the sound limb. The leg is readily bent and extended by the hands of the surgeon, and without pain to the patient. At most, the degee of uneasiness caused by this flexion or extension is trifling, but the patient himself cannot freely bend or extend the limb in walking; he is com- pelled to walk with an invariable and small degree of flexion ; yet in sitting down the affected joint will move like the other." Bonnet, from experiments on the dead subject, confirms Knott's views of what takes place in these cases, and shows clearly that it is produced by twisting the leg outward when the limb is slightly flexed. Certainly there is no laceration or extensive displacement of any internal structure. Sir Astley Cooper wrote of it in much the same terms, stating that it may be produced by striking the inner side of the great toe against any slight projection, when the knee is bent as in walking. I have seen the same thing myself on several occa- sions, but the most interesting example with which I am ac- quainted was told me by a medical man of himself. During his student days, while playing at football, he suddenly made a violent kick, missed his aim, and fell down, feeling very sick, with intense pain on the inner side of his knee. He was entirely unable to move the joint, but after a friend had slowly flexed the limb as much as he could, and then rapidly extended it, the pain disappeared all of a sudden, and he could walk as before ; only for some days there was a considerable amount of swelling, and a sense of insecurity about the joint. The same thing happened to him on several occasions afterward. These symptoms agree so closely with those described by Hey, Knott, and Bonnet, that there can be no doubt the actual derangement is the same, though the way in which it is pro- duced is apparently altogether different. I say apparently, because, if the action of the knee joint under these conditions is considered for a moment, the difference completely disap- pears. When the leg is extended, just as it comes to lie in the same straight line with the thigh, a slight amount of rotation outward takes place at the knee joint, so that the ligaments become tense, and the joint sufficiently secure to bear the 176 Sprains; their Consequences and Treatment. weight of the body in walking. In this particular instance extension was extremely rapid and vigorous; there was no weight resting on the limb to keep the bones in apposition, and, consequently, there was nothing to check the rotation outward. This allowed the posterior margin of the internal cartilage to be carried forward until it was caught and fixed by the spasmodic contraction of the muscles. Voluntary movement at once became out of the question. I have since been told that accidents of a similar character, only not suf- ficiently severe to cause any actual displacement, are not un- common at football; there is merely a sickening pain on the inner side of the joint for a few minutes, and in some instances a slight amount of effusion afterward; but the displacement is not carried far enough for the cartilage to be caught and fixed. Reduction. The method of reduction has been already mentioned; nothing is easier when once it is understood, es- pecially if the patient is under an anaesthetic. Hey recom- mended making him sit on a high chair, facing the surgeon, who should grasp the limb firmly, extend it until it was as straight as the circumstances w r ould allow, and then rapidly flex it again. Later surgeons have reversed this proceeding with some advantages, as preliminary extension is much more painful than flexion, and in the second step rapid flexion is somewhat difficult to carry out. Whichever way is adopted, while it is being done firm pressure must be made with the thumb of the disengaged hand over the position of the displaced cartilage. As soon as free movement is restored the limb is carefully padded with cotton wool, and thoroughly bandaged to prevent any accidental redisplacement, and to limit the effu- sion that is almost certain to follow After Treatment. This apparently trivial precaution should never be omitted. The chief danger of this singular accident is its extraordinary liability to occur again and again. If the effusion is not checked at once the capsule and the liga- ments yield until the natural tension of the joint is lost, and the displacement becomes easier than ever. When once a commencement has been made these two things act and react continually on each other; each displacement causes a fresh amount of effusion; each time the effusion occurs it makes the displacement more easy. At length it often happens that Sprains; their Consequences and Treatment. 1/7 the distention becomes chronic and that the joint is seriously disabled, though it must be admitted that when this has happened the displacement does not cause so much pain as it did. After the effusion has been absorbed it is always advisable to wear a retentive apparatus for some months, especially when indulging- in any exertion which, like lawn-tennis, has a particular tendency to produce this derangement. If it has only happened once, an elastic knee-cap, strengthened and padded opposite the internal cartilage, may suffice; but care must be taken with an appliance of this description that more harm than good does not result. It must never be worn at night ; and when it is taken off the knee should be thoroughly rubbed and kneaded to restore the circulation through it, or else the tissues waste away and the elastic becomes so com- fortable that it is regarded by the patient as indispensable. If one of the attachments of the cartilage has been torn, so that there is a definite displacement recognized by the projec- tion it forms beneath the skin, on the outer or the inner side of the joint, this is not sufficient. Either a mechanical con- trivance must be worn for the purpose of checking irregular movements of the leg when the lateral ligaments are slightly relaxed, or else, as Annandale has done on several occasions, with conspicuous success, the joint must be opened, and the offending cartilage stitched into position. A very good arrangement for cases of this kind consists of two well-padded metal plates accurately fitted round the knee-cap, one on either side and held together above and below by short straps. These plates are connected together by a steel spring passing horizontally across behind the joint, so that when the splint is in position they press firmly on the unprotected portion of the capsule, where the displacement is most likely to occur. If this does not answer, or if it is thought, from an examination of the case, that the derangement in the case of the internal cartilage is really due rather to outward rotation of the leg while the ligaments are relaxed, the best kind of apparatus is formed on the principle of two lateral bars jointed opposite the knee, and connected together above and below by a circle round the limb, formed partly of metal and partly of leather. An additional strap across the joint above and below the patella is sometimes of service. This is 178 Sprains; their Consequences and Treatment. heavier and more cumbersome, but much, more efficient than the former in checking- irregular movements of rotation in either direction. Flexion and extension are not in the least impeded, and after the patient has once grown accustomed to it even lawn-tennis is possible in it. CHAPTEE XIY. CONTRACTION OF THE FINGERS. IT sometimes happens that sprains, instead of running an ordinary course, are liable to be followed by unusual results, due either to some peculiarities of structure in the part itself, or to the presence of an overpowering 1 constitutional taint, or to the influence of both together. One of these, which occurs in the hand, tying down the fingers, and giving rise to serious inconvenience from the way in which it interferes with their movements, is known as Dupuytren's contraction. Structure. The whole of the palm of the hand is invested by a sheet of dense fibrous tissue, which forms a sheath round all the muscles, and is closely united to the skin on one surface and the bones on the other. In the centre it is exceedingly strong, stretching over the tendons and retaining them securely in all the movements which the hand executes. It is to this, in great measure, that the palm owes its firm resisting feel. At the sides, where it is continued over the muscles of the thumb and little finger, the thickness is not so gre of finger contraction, 182 of sprains, 82 of sprains by application of cold. 83 of sprains by application of heat, 88 of sprains by application of pressure, 91 of tendon sprains, 142 of tendon sprains by massage, 144 of tendon sprains by passive movement, 145 of tendon sprains by pressure, 144 WARMTH for relief of muscular pain, 163 Wasting, muscular, 201 of extensor muscles, 203 of muscles from compression, 202 of muscles from inflammation, 204 of muscles from overwork, 206 Whole limb should be carefully examined, 31 YIELDING joints, 9 Date Due DEC 7 1970 CAT. NO. 23 233 PRINTED IN U.S.A. 000510470 WE175 M926s Moullin. Sprains; their consequences and treatment WE175 M926s 1891 Moullin. Sprains; their consequences and treatment CALIFORNIA COLLEGE OF MEDICINE LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664