Manipulative Surgery

Although particular emphasis has been laid on adhesion in connection with joints, it is most important to remember that this may occur in many other important situations, particularly in the vicinity of muscles, or in their sheaths, or between different groups of muscles. This may also occur in connection with tendons and their sheaths, and in fascial or connective-tissue structures.

Functional or Hysterical Cases.---These

constitute an inter esting and important group in which good results by manipulation are sometimes attained. It must be remembered that a functional case is primarily mental and this condition is particularly apt to occur after injury in a person of nervous temperament. Although there is no actual organic disease of the joint—at any rate in the early stages—yet it is extraordinary how a functional condition of a joint may simulate some organic disability of the same joint. Great experience and clinical acumen are often required to form a correct diagnosis of such types.

The great value of manipulation in these cases is that a vicious circle is thereby broken, and, although an anaesthetic is not abso lutely essential, yet, if some such anaesthetic as gas or gas and oxygen be given, it has a powerful suggestive effect upon the patient. It is usually found that, as soon as the patient is under the influence of the anaesthetic, the joint, which previously was held awkwardly and stiffly, becomes relaxed. The manipulator places the joint in the position which was erstwhile impossible and retains it thus until the patient is fully conscious. The patient is then shown the increased mobility and encouraged immediately to move the joint through this increased range. Much subse

quently depends upon the patient being surrounded by an atmos phere of cheerfulness and encouragement, and everyone with whom the patient comes in contact must endeavour to play his or her part in the cure and to assure the patient of its completeness and finality.

In cases of long standing, actual organic changes may occur in an hysterical contracture, and the contracture, which was pre viously due to muscular sprain, becomes fixed by scar tissue. It is therefore important that manipulation should not be delayed too long, especially as the mental state becomes more fixed and more difficult to treat with the passage of years.

Cases Partially Relieved by Manipulation.

This large group includes a great many conditions due to disease rather than injury, the principal probably being the group of infections and intoxications usually known by the name "rheun'iatic," especially in its more chronic forms. Here again it is obvious that those cases in which only a slight degree of stiffness of a joint is present are much more satisfactory from the point of view of treatment than cases of marked stiffness or cases in which well marked de struction of the joint surfaces has occurred. It is important also to wait until all signs of activity have subsided and furthermore to eradicate the cause wherever possible before having recourse to manipulative measures. In nearly all cases of strains and sprains gentle manipulation at the earliest moment is recommended be cause the reparative processes of nature act most effectually when, as far as possible, no interference whatever with their functions is resorted to. (See JOINTS AND LIGAMENTS : Diseases and Injuries.) (H. BAR.)