At the beginning of February 1898 I called attention in the 'Lancet' to the use of massage in recent fractures, a treatment which had previously received too little notice in this country. After having had some experience of it I then came to the conclusion that, rationally practised, this treatment was probably the best method which could be used in the majority of ordinary fractures, both simple and compound, when the circumstances of the practitioner and of the patient permitted its adoption. The result of that communication was a considerable increase in the use of the method. It has been employed freely in St. George's Hospital with excellent results. Latterly, however, there has been some falling off in its use - not because there is anything wrong in the principle of the method or with its results, but because it is at times difficult to keep the necessary number of dressers, who of course are constantly changing, sufficiently instructed in the details to enable it to be safely carried out. I have, therefore, thought that it might be useful to devote some time to a practical description of the way in which the treatment should be applied.

I do not propose to confine my remarks altogether in these lectures to massage in fracture, as I think it will be useful to deal generally also with the legitimate use of rational massage in common surgical injuries. In other words, I shall try to say something useful about the treatment of recent fractures, of dislocations, and of sprains and bruises by the same means. It is possible that I may be able to say something useful about the treatment of each of these varieties of injury; at all events, I hope the time spent in considering the matter will not be entirely wasted.

The Use of Massage and Early Movement in Recent Fractures.

It is well known that the real difficulties and disappointments in cases of fracture, when they are treated in the ordinary way, often commence after the union has taken place and the patient begins to think of getting about. There are, of course, initial difficulties in connection with the 'setting' of the bones and in the subsequent keeping of the fragments properly in place; but these, as a rule, cause no great trouble provided they are intelligently met. The difficulties in the later stages are mainly pain and stiffness, which frequently require a long and trying course of massage and passive movement to enable the patient to get about with comfort or to follow his occupation, and which sometimes lead to permanent crippling. In the case, for example, of a fracture of the leg treated in the ordinary way by having been placed in splints or in plaster of Paris, or in some other contrivance of that kind, for a long period, say from six to eight weeks, it will be found that when the splint, of whatever kind it may be, is taken off and the patient begins to walk about or tries to walk about, complaint is frequently made of intolerable pain about the ankle and sometimes across the sole of the foot. The ankle is stiff, the knee may also be stiff, and the muscles are wasted, so that the leg may be little more than bone and skin. Supposing, however, that the case has been treated rationally by massage and movements from the beginning, it will be found that the patient is afflicted with none of these troubles; the ankle is not stiff, there is no pain such as I have mentioned, and the muscles are not wasted, because when massage and early movements are used they are prevented from shrinking; in fact, when the patient begins to get about the ankle is free and supple, and the muscles are almost in the same condition as those of the sound limb. These are obvious and great advantages. The reasons of the discomfort which patients suffer when the treatment has been conducted upon classical lines are easily explained. The stiffness is due to the fact that in consequence of the limb having been placed in an immovable splint for a long period the joint included in the splints becomes, as a matter of course, temporarily stiff. If, for example, a perfectly healthy ankle-joint were put into a plaster-of-Paris splint for several months it would be found upon the removal of the splint that the natural mobility of the joint could only be obtained at the expense of some pain and discomfort. In fracture the stiffness is of course infinitely increased by the adhesions of the soft part around the seat of the lesion.

A noteworthy pain in fracture of the leg is that which shoots downwards from the seat of the fracture along the back of the leg, behind the inner malleolus, and thence into the sole of the foot. This pain is sometimes most acute, and at times leads to permanent crippling: it is due to neuritis produced by the parts about the fracture becoming matted at the level of the injury; this matting sometimes involves the posterior tibial nerve, and so gives rise to the neuritis. This condition is no imaginary one, since I have proved it by dissection.1 The result of this condition is that when the patient begins to try to use the limb after the mere stiffness due to the splints has been overcome, any free movement of the foot causes a dragging upon the adherent nerve, so that an intense neuralgic pain is caused. So acute is this pain in some cases that it prevents the patient proceeding further with attempts to get better movement. People are therefore sometimes seen walking with stiff ankles after fractures of the leg which have been treated by persistent splinting, not because the stiffness cannot be overcome, but because the pain on movement of the ankle is so great that they are unable to bear the necessary manipulation. All this trouble is preventable by the use of intelligent massage and movements in the early stages of the treatment. In the early stages of fracture the main difficulty is, as I have already said, connected with the setting of the bones, the difficulties arising in this respect being mainly three. One is the ordinary nervousness of the patient, which, of course, can only be overcome by tactful management or by the administration of an anaesthetic; the second is connected with the direction or other peculiarity of the fracture; and the third difficulty arises from muscular spasm, the result, no doubt, either of irritation of the muscles by sharp edges of bone or of direct laceration of the muscles themselves, which in consequence become hypersensitive and excitable. I know of nothing more difficult to relieve under ordinary circumstances than the muscular spasm which comes on after the injury in some cases of fracture. Not only is it painful to the patient, but the constant muscular contractions frequently render the retention of the fragments in proper position almost impossible. In the old times - and with some people it is even the custom now - it was sought to overcome this spasm by tenotomy; and since spasm is more commonly met with in the muscles of the calf than elsewhere, division of the tendo Achillis was the operation most frequently performed with this object, because it was thought that division of the tendon would for the time being paralyse the gastrocnemius and soleus, and would permit of the proper adjustment and retention in position of the fragments which could not be otherwise accomplished. It is not unusual after the reduction of a fracture with or without the aid of an anaesthetic - we will, for an example, take the case of the leg - to find when the patient recovers consciousness that uncontrollable spasm occurs; the pain is acute, muscular contraction is inevitable, and if the fracture is at all oblique the displacement recurs. Spasm of this kind is more efficiently controlled by massage than by any other plan, excepting perhaps by prolonged general anaesthesia or by narcotism by opium, alternatives which are obviously undesirable in ordinary circumstances.

1 The Lancet, February 5, 1898, p. 359.