The habitual derangement of the shoul der joint—sometimes on the slightest provocation, such as sneez ing, stretching or ordinary reaching—is a most troublesome affec tion and is usually attributed to a rent or tear in the capsule, brought about in the first instance by a severe wrench, although cases could be recorded where no history of accident can be re membered. The disability is probably more often caused by adhesive contracture of a section of the capsule with an accom panying exaggerated relaxation of the remaining portion which allows the dislocation to take place. Although surgeons frequently advise a surgical operation, certain manipulations bring about a condition of the capsule which will enable it to exercise normal control of the head of the bone followed by exercises designed to re-establish the surrounding weakened tissues. Out of a number of cases only two or three can be remembered as not having yielded satisfactorily to treatment. The procedure, under an anaesthetic, is quite devoid of danger, and the after-effects are of brief duration and only slightly painful.
The actual reductions of gross dislocations do not enter to any great extent into the purlieu of the manipulative surgeon. There is, however, a large number of conditions due to minor displacements which constitute an im portant branch of his work. Principal among these must be placed displacements and fracture-displacements of the semi lunar cartilages of the knee-joint. This field is an enormous and most important one, for the number of persons of both sexes who sustain such injuries is legion. In original unreduced displace ments, reduction must be carried out by appropriate manipulation at the earliest possible moment. In chronic or recurrent cases, manipulation is also very frequently effective in bringing about a cure of a very troublesome and disabling condition.
The brilliant results obtained in this type of case have been known for many years, but the underlying pathology has been a profound puzzle until it was recently shown: (a) that by far the commonest type of injury of the internal semi-lunar cartilage is the complete longitudinal tear; (b) that in this type of case, the outer portion of cartilage is nearly always found in the interior of the joint; (c) that by appropriate manipulative technique this displaced fragment may be made to retrace its steps and come into apposi tion with the inner fragment ; (d) that when this has been effected, there is a good chance of repair occurring between the two fragments.
These constitute another important class. It is essential first of all to make quite clear what we mean
by the term "adhesion." It is probably known to most that an inflammatory process is usually accompanied by the exudation of lymph from the blood-vessels of the part. This lymph tends after a short while to become organized, i.e., changed into con nective tissue, or, as it is usually called, "fibrous tissue." Let us imagine, for example, that owing to a severe sprain of the knee the lining membrane of the joint has become inflamed. As a result there is an outpouring of this lymph by the blood-vessels of the membrane, and various folds and layers of this self-same membrane tend to become adherent by this inflammatory exu date. When this has become converted into fibrous tissue, ad hesions are actually present which may give rise to marked dis ability. It is characteristic of adhesions, that, when pulled upon or stretched, severe pain usually results. Further adhesions give rise to a variable amount of limitation of some particular move ment or movements of the joint, which is apt to be overlooked unless a most careful examination be made.
Swelling of the joint after exercise, muscular wasting and a sensation of weakness and often an actual giving-way of the joint, are not infrequent characteristics of adhesions.
As previously stressed, the doctrine "rest inflamed structures" has been responsible for the formation of countless thousands of joints disabled by adhesions. However true the doctrine may be in certain other organs and structures of the body, and even this is debatable, in the case of a joint it is dangerous, for the function of a joint is movement and movement must always be instituted at the earliest possible moment in almost any inflammatory condition, except in those ultra-acute conditions where movement is impossible and in some cases of tubercular disease and of myositis ossificans. When a joint has become crippled owing to the presence of adhesions, how is the joint to be restored to its pristine health and vigour? The answer is manipulation.
It is obviously impossible, in a short article of this nature, to detail the various technical methods of manipulation that apply to the different joints. Anaesthesia, although not absolutely essen tial, is a valuable aid in many cases, owing to the complete mus cular relaxation thereby attained. The cases that are attended with the greatest success are those in which the adhesions are slight and in which the subsequent reaction is negligible. In more marked cases much benefit often follows from a series of manipu lations separated by short intervals.