injured part. It is more often observed in nervous individuals, who exaggerate the importance of the injury and discomfort that it causes. In such cases, the limb

may be discolored by venous congestion, the part may be edematous, and the movements may be limited by adhesions or by muscular adaptation to the habitual attitude.

Treatment of chronic sprains must be conducted with the aim of restoring the normal range of motion and so supporting the part that normal functional use may be permitted. If adhesions have formed, and if the part is persistently held in an abnormal attitude, forcible manipulation under anesthesia may be required as a preliminary treatment, followed by fixation for a time in a plaster bandage in the attitude directly opposed to that which has been habitual. When all discomfort has disappeared, a support should be worn for a time. The most effective after-treatment is passive and active exercise.

In conclusion, allow me to say that notwithstanding the fact that the traditions of the profession required absolute rest of the affected parts after injury to the joint, we now know conclusively that massage and then exercise applied early, and with a suitable degree of skill and perseverance, effects a more speedy cure in most cases of sprains than absolute immobility, and prevents both the loss of movement, which usually occurs, and the muscular atrophy which is the natural result of absolute rest and immobility.

DISCUSSION ON DR. TOEPEL'S PAPER.

Dr. W. H. Aycock, Molena: I have been much interested in the paper, having had myself a very severe case of fracture of the ankle joint. I put it up in adhesive strips for a few days and after that in plaster of

paris for several weeks. The patient was then able to walk a little, but it was several months before she had good use of that joint.

Dr. A. L. Fowler, Atlanta: I rise simply to endorse Dr. Toepel's method of treating sprains, particularly sprains that have assumed the chronic form. I have in mind, at the present moment, two cases of chronic sprains that I referred to the doctor: one of them an old and chronic sprain of the knee-joint, the result of a railroad collision. This injury was treated promptly, and in accordance with the usual plans of treatment, elevation of the part and uniform bandages, and as soon as the swelling sufficiently subsided a plaster of paris cast was applied and passive motion at intervals was employed. Later the case was referred to the doctor who used dry heat in conjunction with massage, passive and resistive exercises, and when I last saw the patient he had practically recovered. Recently I referred another case to him, that of an old sprain of the ankle-joint, and which had been treated by another physician some time before it came to me. I treated the injury along the old established lines and the patient was slightly benefited. I then referred the case to the doctor, and under the particular plan of treatment that he has outlined the patient made satisfactory recovery.

Dr. Floyd W. McRae, Atlanta: I wish to discuss the paper from the standpoint of not agreeing with the doctor in every particular. In the first place, the treatment is impracticable for the average doctor and for the average patient. We must have a plan of treatment that will reach the case under normal conditions. It seems to me the adhesive strips give a plan of treating sprains in a very satisfactory manner, and personally I should hate very much to see that treatment condemned by an

association of practitioners. In the average sprain of the ankle or wrist, or of the knee, you may strip them properly, put on a bandage, and if it be the ankle, put on a shoe and let them go right on walking. The movement of the joint is the natural massage, and the result is restoration of the joint function. The large majority of the gentlemen present, I am sure, have had good results with this method of treatment. Now, in chronic sprains, those that have been improperly treated or not treated at all, I do not know of any treatment so good as that suggested by the doctor of baking and massage, but I do not think it the best way to treat the average recent sprain.

Dr. W. B. Standifer, Blakely: I wish to commend what Dr. McRae has just said as to the use of adhesive strips and casts in recent sprains. I always put them up in plaster of paris, and have yet to find or record a failure.

Dr. W. B. Armstrong, Atlanta: In treating sprains we will occasionally find an old obstinate sprain that nothing will improve, and within the last few years in all of these cases I have made it a practice to examine the urine for signs of proteid decomposition, and in every case have found it to exist. By putting these patients on an anti-putrefactive diet, fermented milk, and leaving off yeast and potatoes they improve. I think most of these obstinate cases are so on account of intestinal putrefaction rather than on account of lack of proper mechanical treatment.

Dr. Theodore Toepel, Atlanta (closing): It was my intention to bring out the value of the resisted movement exercises when you have the opportunity of being near the patient. I did not discredit the use of the adhesivestrip treatment. The country practitioner or any other

practitioner who can not be near his patient would have a hard time to carry out this treatment, but if you can get the patient to come to you or you can go to see the patient and still use the plaster of paris bandage with the massage and the resisted movement exercises where you can localize the exercise and strengthen only the stretched ligaments, it is better than the adhesive-strip treatment. General exercise is not best; you involve the healthy tendons as much as the diseased one, which you do not want to do.

"CRUSHES OF THE EXTREMITIES."

BY THOS. H. HANCOCK, M.D., ATLANTA.

These accidents may occur in the country or small towns, and the rule is to take them to the nearest city. This may be a good procedure in many cases where the loss of blood has not been great and the shock is not marked, but even the crushes of the arm, forearm or foot should not be neglected, as many of them have proved fatal.

Since we may have such an accident out in the country entirely away from a physician, the layman should know how to control hemorrhage. Constriction of the limb just above the injury is easily made by a piece of bell cord, a suspender or a handkerchief. The mistake usually made is that they are not drawn tight enough, and a moderate compression increases the venous flow. These improvised tourniquets become very painful even when they are applied near the crushed area, if left on very long, and may add to the shock. Whiskey in moderation will be a great help until the physician arrives, when he can give a few whiffs of chloroform, if he knows how to give it; or ether, if he does not, as all doctors can give ether. Then he can easily cut away the mangled tissue and tie most of the bleeding vessels. If he is embarrassed by any bleeding points which he can not catch, he has simply to thread a curved needle with a piece of catgut and take a stitch through the tissues in such a manner as to include the vessel. I have tied the superficial palmar arch in this way. The hemorrhage having been controlled, the wound should