DISCOVERY 



121 



Many other unsatisfactory after-results of old- 

 fashioned methods of treatment of injuries such 

 as sprains, dislocations, etc., are attributable to the 

 lack of care for the muscles during the process of 

 recovery. .A. man, for example, is laid up for throe 

 weeks with a sprained ankle ; he gets up, finds his 

 foot " weak," and develops a flat foot. The fact is 

 that the muscles supporting his instep have so far 

 wasted that they are unequal to their task ; the 

 ligaments, ne.xt feeling the strain from the super- 

 imposed body-weight, give wa}', and the arch of the 

 foot drops. Occurrences like these wiU become rarer 

 and rarer, just as stiff limbs after fractures are becoming 

 less common, in proportion as the newer principles of 

 treatment become more widely understood and prac- 

 tised. There is not yet the same wide acceptance of 

 the principle of early movements in the case of fresh 

 sprains ; many eminent orthopaedic surgeons have 

 adopted it, realising that here, as in the case of frac- 

 tures, it is the extent and force of movement which 

 determine disaster or success. 



Treatment by graduated contractions with increasing 

 amplitude of movement of the sprained joint, for 

 twenty minutes daily, serves admirably to maintain 

 muscle health and hinder the adhesion of the various 

 tissues. All this at a stage when voluntary move- 

 ments would be painful and quite inappropriate. 

 For these fresh sprains there is, of course, everything 

 to be gained by emplojdng massage, also, for the 

 removal of fluid in the swelling and for the alleviation 

 of pain. 



Sprains of " joints " (i.e. really of ligaments) and 

 sprains of muscles are much relieved if the obvious 

 procedure be employed of preventing tension on the 

 damaged structure. The realisation of the value of 

 this we really owe to the Liverpool school, and, like all 

 Owen Thomas's methods, it is attained by quite 

 simple means. At the ankle, the object can be 

 achieved by " crooking " the heel with a ^-inch 

 wedge of leather on one or other side ; but a 

 " rider's strain," which under treatment by massage 

 and strappings may prevent hunting for one season 

 after another, is often amenable to nothing but a 

 course of graduated contraction for the damaged 

 muscle. 



Of favourable terminations to acutely inflamed 

 joints (as after penetration by a sharp instrument or 

 projectile) anchylosis is at present commonest. While 

 much more crippling in the upper than the lower limb, 

 the limb may stiU be fairly useful if union of the two 

 bones occurs in a favourable position. InteUigent 

 anticipation in these cases as to the probable course of 

 the case becomes of supreme importance ; should a 

 shoulder be likely to anchylose, it must be kept from 

 the side at an angle of about 45°, a position in which, 



even with complete anchylosis, considerable and 

 useful movements will be possible by movement of 

 the shoulder-blade with arm in one piece. 



Better than any anchylosis, or subsequent procedures 

 such as the arthroplasty already mentioned, will be a 

 method which aims at primary cure of the inflamma- 

 tion with a movable joint. Colonel Everidge has 

 appUed for inflamed (septic) joints a principle 

 somewhat analogous to the employment of graduated 

 contractions for muscles. Movements insufficient to 

 cause injury, but adjuvant to the normal processes of 

 repair, are obtained by an ingenious arrangement of 

 pulleys (Fig. 3), very slowly and steadily moved by the 

 running of sand through the balancing weights ; and 

 movable joints result where immobilisation would 

 inevitably have ended in anchylosis. Belgian surgeons 

 have obtained similar successful results ; but further 

 experience is necessary to determine the scope and 

 limitations of this promising procedure. 



The employment of X-rays is of great value in 

 orthopedic surgery as in general surgery, but especially 

 so because so much of the surgery of bone falls within 

 the sphere of the orthopaedist. Recently the regular 

 employment of X-rays has revealed the fact that many 

 supposed sprains are compHcated by fractures which 

 would be unrecognisable by other methods of diagnosis. 

 Previously there had been extreme uncertainty as to 

 the prospect of good ultimate cure in these " sprains " ; 

 the assistance thus provided by X-rays is rendering 

 far easier the determination of the proper date at 

 which, for example, weight should be permitted upon 

 an ankle, sprains and fractures being so different in 

 this respect. Wrist and finger " sprains " are, it has 

 been discovered, frequently complicated by such 

 unobtrusive fractures, very disabling, however, when 

 treated by too prolonged rest or, on the other hand, 

 by too early and too vigorous treatment. 



For watching the fate of bone-grafts, for studying 

 the condition of bones and their relationship to sur- 

 rounding parts, the use of X-rays has been one of the 

 chief factors in the recent progress of bone-surgery. 

 Adhesions, whether between joint-surfaces, between 

 tendons and the sheaths within which they run, or 

 between muscles and surrounding structures, are all 

 the result of immobihsation, of lack of the natural 

 movements of the part. Three weeks of this treatment 

 will incapacitate a healthy knee : how fuU of risk, 

 then, when neighbouring injuries have occurred, 

 with their associated swelling, and processes occur 

 which prevent absorption. Adhesions are liable to 

 form after unrecognised injuries of the joint surfaces 

 from small complicating fractures. After the lapse of 

 time, movements become less painful, but in certain 

 positions the pain is still liable to occur from tugging 

 upon the fibrous band into which, by repeated move- 



