Popular Science Monthly/Volume 49/July 1896/Massage in Sprains, Bruises, and Dislocations
By DOUGLAS GRAHAM, M. D.
IN the Life and Letters of Mr. George P. Marsh, Volume I, page 219, is the following account of the brilliant success of the treatment of two sprains by a wild Arab: "There seemed, however, small chance that the proposed journey to Sinai, Petra, Jerusalem, etc., could be carried out. The season was already far advanced for desert travel; Mr. Marsh had seriously sprained his ankle at Karnac while carrying his wife through the great temple, and could not now walk without the assistance of two persons; and Miss Paine had been suffering from a somewhat similar sprain even before leaving Constantinople, and had profited little by the surgical skill of the Pranks at that place or in Egypt. The dragoman, though it was clearly for his interest that the journey should be made, admitted the impossibility of it under these circumstances, and gravely proposed that the two sprains should be cured at once by an Arab doctor of his own acquaintance. He entreated so earnestly and with such apparent confidence in his miracle-worker that a consultation was held with some of the oldest and most intelligent of the Frankish residents at Cairo, and, though no one would exactly take the responsibility of advising it, every one said that the evidence of these immediate cures was such that he should certainly try the experiment in his own case. Some, indeed, had tried it with entire success, and no one thought any harm could come of it.
"These considerations, added to an intense desire to see more of the mysterious East, decided the lame patients to call in the 'radoubeur.' So, the second morning after their installment in their hotel, Achmet presented himself, bringing with him the most extraordinary creature that can be well imagined. He was scarce five feet in height, and was clad in a single garment of blue cotton fastened about the waist with a leather belt. His old, withered face was lighted up by one eye only, and that seemed but half open, while nothing about his person would have led one to believe that the waters of the broad Nile were within reach. There was an unmistakable look of mortification on the part of those who had consented to summon this Æsculapius, but there was no help for it now. At this moment a visitor was announced to Mr. Marsh, and the lady therefore was the first to prove the wild man's skill. He examined the injured foot, placed it in warm water, dipped his own fingers in olive oil, and rubbed and pressed the foot very gently for about twenty minutes. He then carefully dried it and bade his patient walk. She hesitated, having suffered so much and so long from every effort of that kind; but an imperative 'Imsheh, imsheh,' decided her. She placed her foot firmly on the floor and took a step, another and another, and still no pain. In a few minutes she was in the street, and, after strolling some hours among the bazaars of the city, returned without the least feeling of discomfort. The cure was perfect and permanent.
"In the meantime Mr. Marsh had passed through a more severe ordeal at the hands of the magician. His foot and ankle, which were both badly swollen and discolored, were very sensitive to the manipulation, and especially to the energetic pulling which in this case was a part of the treatment, and at the end of three quarters of an hour he was well-nigh exhausted by the pain. But then, on looking at his foot, he was surprised to find that the swelling had disappeared, the color was almost entirely natural, and the shoe and stocking, which had been laid aside for almost two weeks, were put on with perfect ease. He was then directed to walk, which to his amazement he found he could do without the least pain; and the only unpleasant sensation he experienced afterward was a slight stiffness for the first day or two, which, however, did not in the least interfere with walking. After this, preparations for forty days' wandering in the desert were made as rapidly as possible."
Making allowance for the enchantment that distance always lends, there is little doubt that these two injuries were much benefited by the manipulations of the wild Arab. But it is very evident that he hurt his second patient much more than there was any need of. It would, indeed, be strange if the teachings of science did not enable us to improve on the methods of blind instinct. And though science often follows art with limping strides, yet here we can say that science has caught up with art and together they work for the rapid amelioration of disabled joints. No sane person would think of having massage applied immediately to the seat of a sprain, but many imagine that this is what the masseur will do, and hence deprive themselves of the early benefit that might be got from this method of treatment, which quickly relieves the pain, the heat, and the swelling, removes the pressure from terminal nerve filaments, and prevents the parts from sticking together. No two masseurs are alike by nature nor in skill, tact, and education, and the one who knows his anatomy and physiology well, when called to a recent acute sprain, will not begin at once to masser the injured joint, but at a distance above it on the healthy tissues by gentle stroking or effleurage toward the heart, gradually proceeding nearer and nearer to the painful place. This has a soothing effect and pushes the flow along in the veins and lymphatics, making more space in them for the returning currents coming from beyond and carrying away the fluids that have leaked out of the vessels. The same should be done on the part of the limb beyond the joint, for the circulation is hindered both in going out and coming in by reason of the swelling.
Next, the masseur who knows his business will begin again at a safe distance above the injured joint, and use deep rubbing, kneading, or massage properly so called, one hand contracting as the other relaxes, alternately making circular grasps, with the greatest pressure upward, and this should be done on the parts above and below the seat of sprain. By this procedure the effects of the previous stroking or effleurage are much enhanced an analgesic or agreeably benumbing effect is produced upon the nerves which extend to the painful place, and the retarded circulation is pushed along more vigorously, making room in the vessels for the swelling, the effusion, the dammed embargo caused by the landslide of blood and lymph that is inundating the surrounding territory with exudates farther up the stream to float off, and preparing the way for the next step in treatment. At the end of fifteen or twenty minutes of this manner of working, gentle, firm pressure can be made immediately over the swollen and but recently very tender parts, which in a few seconds can have circular motion, with the greatest push upward added to it; and this, if sufficient tact be.used, will in all probability not hurt but be positively agreeable. By this the swelling is spread over greater space, pressed out of the tissues as water is out of a sponge, and brought into more points of contact with the veins and lymphatics by which they are absorbed and carried off; the same pressure that causes the dislodgment of stagnating fluids also aiding absorption by pressing them into the small vessels. Then a snug, well-fitting bandage should be applied, which may exhibit the bungling of a tyro or the skill acquired by twenty years' practice. Under this plan of treatment, used twice a day, the comfort produced and the speed of recovery would scarcely be believed unless experienced by one who had had a similar injury treated in the regular orthodox way, with absolute rest and immobility, by means of fixed dressings.
Some years ago I published the results of massage in more than seven hundred cases of sprains, joint contusions, and distortions of all degrees of severity, treated by many different observers, most of whom were French, German, and Scandinavian army surgeons, in order to confirm the experience obtained in some of my own cases. The invariable result of each and all was that such injuries thus treated got well in one third of the time that similar cases did under the usual method of absolute rest and fixation, and with less tendency to subsequent weakness, pain, and stiffness. Experience teaches that the sooner after a sprain massage is begun, the quicker is the recovery. In Germany the military authorities now require a semiannual report from their surgeons upon the results of massage in injuries of joints; and the statistics of Gasener, Starke, Körner, and others clearly show the rapid results of this method, and the economy of time to the soldier. I fear it will be a long time before many of the physicians and surgeons in the United States will condescend to try their hands at massage; indeed, most physicians adopt, prescribe, or tolerate massage in the same way that Constantine the Great embraced Christianity—more from policy than conviction.
The orthodox treatment of absolute immobility alone in these cases has little else to support it than the dogmatism of centuries, from which it is almost impossible for a surgeon to free himself, unless he has been the unfortunate victim of a sprain, and had it treated with massage. Supposing a prize of ten thousand dollars were offered for the quickest way to make a well joint stiff, what more effectual means could be resorted to than first to give it a wrench or sprain, and then do it up in a fixed dressing, so that the resulting inflammation would have an opportunity of producing adhesion of the parts? And this is the prevailing treatment of sprains. The same plan of treatment is employed for the purpose of closing up holes in other parts of the body—namely, that of exciting adhesive inflammation; and, unfortunately, it sometimes closes the cavity of a joint also.
It would seem as if we had sufficient proof of the beneficial effects of massage in injuries and affections of joints in human beings, without intentionally inflicting similar injuries on animals in order to treat them by massage, and study the effects of this upon them. However, much interesting and confirmatory evidence has resulted from such experiments, and the effects produced are no longer left in the realm of theory, but brought into the sunny light of science and ocular demonstration. The mind of man may be prepossessed in favor of massage, and this would help recovery; of animals it can not be, unless they had had massage before for a similar hurt. Animals that have been treated by massage can be killed and the effects studied and compared with similar injuries in other joints of the same animal that have not had massage. Von Mosengeil, Professor of Surgery at Bonn, injected corresponding joints of rabbits with Indian ink. Witb each rabbit he masséed one of the joints at regular intervals, and left the same joint in the other limb untouched. The swelling and stiffness caused by the injection rapidly disappeared under massage, and on examination of the masséed joint after the animal was killed it was found empty of its colored contents. Even when the examination was made shortly after the injection and the use of massage, there was scarcely any ink found in the joint; part of it was found upon the synovial membrane, and upon microscopical examination it was seen that the greatest part of it had been forced into and penetrated through the synovial membrane. The darkened lymphatics could even be seen with the unaided eye extending from the injected joint to the lymphatic glands in the groin or axilla, and these latter were also black from the absorption of the ink. Upon examination of the joint cavities that had not been masséed, the ink was found in the joint, mixed with the synovia, forming a smeary mass, and it had not even penetrated the tissue of the synovial membrane. The same results were uniformly obtained in all the experiments, showing that absorption takes place from joint cavities by means of lymph spaces and small openings communicating with lymphatic vessels, and through these with lymphatic glands.
But by far the most interesting experiments yet performed to elucidate the effects of massage on joints, muscles, and nerves are those described at length in the Archives générales de Médecine for 1891 and 1892. Having obtained excellent results from massage in bruises of joints and muscles, in sprains and dislocations, and also in fractures, some of which were masséed from the commencement of the injury when there was no displacement, and others where there was displacement, after a fixed dressing had been applied as short a time as possible to keep the parts in place, M. Castex sought further opportunities to study more exactly the results of these injuries by intentionally producing them in corresponding places in two limbs of dogs, masséing the seat of one of these injuries and letting the other alone, and after five or six months killing the animals and examining the tissues that had been hurt under the microscope. He always chose the more injured limb for treatment and the other had no massage, but was left to the natural evolutions of the injuries. The effects, immediate, consecutive, and remote, were carefully noted by experts in laboratory work, who were not told which leg had been massêed. The experiments were done in the laboratory of Prof. Richet. The massage was done either immediately or very soon after the injuries—even in the case of the dislocations, as soon as they were set—and always with marked relief to the pain, swelling, and stiffness; so much, indeed, that after a few massages of five or ten minutes each of frictions and pétrissage once a day, the dog had full use of the leg that had been masséed, whereas the leg that had not been masséed remained swollen, stiff, and painful for a long time, and in some did not recover at all. It is but fair to state that, no matter how severelysome of the dogs were injured, especially the shepherd dogs, they did not seem to mind it at all after it was over, running about as if nothing had happened as soon as they were set at liberty. These were not chosen for massage. The details are amazingly interesting, but space forbids mention of more than one of the experiments, which may be taken as a fair sample.
The two shoulder joints of a large watchdog were dislocated by inward flexion. The head of the humerus of each was plainly visible under the skin, showing a luxation forward and inward—intracoracoid. It was easily reduced, put back in place, by traction. Five minutes of massage was at once given to the right shoulder, which seemed to afford relief, judging from the grateful way in which the animal submitted; and after this a figure-of-8 bandage was applied around both shoulders. He had massage five minutes daily to the right shoulder alone, and for the first three days he walked with difficulty. The right shoulder gradually became less painful to touch, and he stood firmer on this side. On the fourth and subsequent days all sorts of pressure upon the masséed shoulder were borne without discomfort; but when the other shoulder was pressed the dog growled and attempted to bite. Six days after the dislocations he supported himself well in the masséed limb, but held the other up, as the non-masséed shoulder was still swollen and painful. Both shoulders then staid in place, in spite of passive movements that might have dislocated them. On the eighth day the dog walked well with the masséed limb, but held the other up, as the latter was still swollen and painful, and there was crepitation in the joint. Thirteen days after the injury the dog took an occasional step with the limb that had not been masséed, and two months later it was in about the same condition, while he made free use of the limb that had been masséed in walking and running. There was then atrophy (wasting) of the muscles of the left shoulder, evident by the prominence of the bones; none, of the muscles of the right.
Testimony in favor of the early use of massage in dislocations in human beings, being careful not to move nor disturb the joint, is gradually accumulating. Not only M. Castex, but also MM. Fége, Archambaud, and others, have reported more favorable results from its application from the very first day of the injury than when it had not been used. Passive motion, I think, should not be begun until the patients find that they can make a little voluntary motion. Fifteen or twenty days of this treatment seems to be all that is necessary in mankind; and this is just about the length of time required for the repair of the rent in the capsule. In the meantime, the surrounding tissues are preserved in health and activity by means of the massage.
Soon after the swelling from the injuries to the dogs had subsided the muscles became more or less atrophied in the limb that had not been masséed, but not at all in the limb that had been masséed. At the end of five or six months the dogs were killed and the tissues examined by the microscope. The muscular tissue of the side that had not been masséed presented a diffuse sclerosis or hardening; the connective tissue intervening between the fibers and bundles of fibers was thickened; there were interstitial hæmorrhages, especially in the cellular tissue around the
Fig. 2 shows that the natural size of the intermuscular connective tissue has been preserved, while Fig. 1 shows the intermuscular tissue thickened, and the muscular bundles thinner and compressed. (From the Archives générales de Médecine, Fevrier, 1892, p. 197.)
muscles; the internal and external coverings of the bundles of muscular fibers (perimysia) were infiltrated with blood, and also the fascia or covering outside of this. The transverse markings of the muscular fibers (striæ) were effaced in many places, while the longitudinal striation or marking, which is not seen normally, was very distinct. The muscular tissue from the corresponding region that had been masséed was found to be normal in every particular. M. Castex has left us to surmise the appearance of the sarcolemma or covering of the individual fibers. In all probability this also was hardened, thickened, and infiltrated with blood as were the outer and larger coverings.
The blood-vessels appeared perfectly natural from the masséed side, but from the side that had not been masséed they presented a hyperplasia or thickening of their external coat.
The nerve filaments were found to be natural in the masséed side, while in the side that had not been masséed there were abundant evidences of neuritis, and perineuritis exerting destructive compression upon the nerve fibers. The perineurium, or sheath covering the bundles of nerve fibers, was at least three times as thick in the non-masséed side, and the connective tissue around the perineurium was also thickened with numerous new-formed cells. The small vessels in the perineurium were also the seat of a peripheral hyperplasia or thickening. The lesion of the nerves was more marked than that of the vessels.
These experiments of M. Castex give more emphasis than ever to the remarks of old Arrian in the year of our Lord 243, that "great is the advantage of rubbing to the dog, not less than to
the horse, for it is good to knit and to strengthen the limbs, and it makes the hair soft and its hue glossy, and it cleanses the skin from its impurities. One should rub the back and the loins with the right hand, placing the left under the belly in order that the dog may not be hurt by being squeezed from above into a crouching position; and the ribs should be rubbed with both hands, and the buttocks as far as the feet, and the shoulder blades as well. And when they seem to have had enough, lift her up by the tail, and, having given her a stretching, let her go. And she will shake herself when let go, and show that she liked the treatment." (Arrian Cynegeticus.)
In human beings M. Castex found that when massage was begun early or from the very first in contusions, sprains, and dislocations not only were the immediate symptoms soon relieved, but also the subsequent serious consequences that are so apt to follow these injuries—wasting, weakness, contraction, and stiffness—were prevented. But when he tried massage in old cases of muscular atrophy or wasting following injuries to joints he got no increase of muscular tissue. The stiffness was got rid of; the muscles became suppler, but they still remained thin and lacking in strength. If he had combined passive and active movements with the massage he would probably have gained growth of muscle. He found that the galvanic and faradic currents were of benefit in promoting increase of muscular tissue. Muscular contraction produced by electricity is but another form of motion.
Numerous theories as to the cause of muscular atrophy from injuries to joints have been considered and abandoned. The most probable and most generally accepted is that of reflex action. The injury to the joint starts up more or less inflammation (arthritis); the articular nerves are irritated; this irritation is transferred to the spinal cord; the nerve centers affected act in turn upon the centrifugal nerves going to the muscles, and these determine at their peripheral ends the muscular atrophy. With a view to the elucidation of this, M. Deroche has repeated seven times, and always with the same results, experiments which were done for the first time at the College of France by MM. Raymond and Onanoff. He divided the posterior roots of the three last lumbar nerves on the left side in dogs and rabbits. After cicatrization had taken place he assured himself that numbness was complete from the thigh to the knee of the left lower limb, so that irritation of this region was not felt. The corresponding limb was left intact. An arthritis was then excited in both knees by introducing a thermo-cautery into them. No pain was felt in the left knee, but much in the right. Three months afterward the animals were killed, and in both knees the lesions of arthritis were found; but the muscles of the thigh of the left leg were of natural size; of the right, atrophied.
Prof. Simon Duplay and M. Cazin have also made a careful study of this subject in much the same way. Under the microscope they found that the articular filaments always presented signs of inflammation; but the large nerve trunks and spinal cord showed no appreciable change, and the results of the examination of the muscles were negative except as to diminution in size. They therefore concluded that muscular atrophies consecutive to joint injuries consist of simple atrophy, and that this can only be explained by a dynamic action, a simple reflex due to irritation of the terminal nerve filaments of the articular nerves.
M. Deroche thought he found that the muscular atrophy was due to diminution of interfibrillary substance, and that there was an ascending degeneration of the posterior columns on the same side. However that may be, the inference is certainly justifiable that massage acts to prevent muscular atrophy by maintaining an influence, a movement, or something in the muscles which the spinal cord is for a time unable to impart to them; and in order to do this, it should be applied immediately or soon after the injury, for then it is more quickly aroused from the lethargy and stupor into which it has been plunged by the shock of the accident.