The possibility also should be remembered that the torn ligament may fail to unite properly, because a portion of it projects into the joint and is nipped between the articular surfaces. This may give rise to serious disability.

Diagnosis.

The diagnosis is made by the tenderness, undue mobility allowed by the laxity of the injured ligament when the case is seen early, ecchymosis, and absence of fracture of the malleoli or torsal bones. Pain is always sudden and may persist.

When there is considerable effusion of blood into and about the joint it may be impossible to detect a fracture without a radiographic examination. So that, in the absence of displacement, such fractures are very often overlooked and treated as sprains. Therefore, in a doubtful case, the injury should be treated as a fracture. Treatment.

It will be seen from the foregoing statements that a sprain of the ankle is not a matter to be lightly considered. The persistent trouble that so frequently follows a sprain is undoubtedly due to the imperfect appreciation of the bad results that follow neglect.

This explains the reason for the popular saying that "A sprain is worse than a break." It has been a common experience of many to obtain better results from treating fractures than from treating sprains, the real reason being that the requisite amount of care has not been bestowed on the spain.

The treatment of a sprain must obviously depend to a large extent upon the severity of the injury.

For clearness we may divide sprains of the ankle into three classes:

1. Into the mild form, where there is simply overstretching of the ligaments, and perhaps no extravasation of blood, or very little. 2. In the medium form, where there is less or more rupture of the fibres of some of the ligaments, with little or much extravasation of blood.

3. In the severe form, where there is complete rupture of some of the ligaments, but not sufficient to produce actual dislocation, accompanied by much effusion of blood and injury to the tissues. Treatment in General.

The first indication in treatment is clearly to check the extravasation of blood into the joint and surrounding tissues.

The second is to promote absorption of blood already effused. The third is to obtain satisfactory healing of the injured ligaments, and to restore the movements of the joint to their normal

range.

In every case the treatment should commence with free movements of the joint in all directions, so as to make sure that no portions of the torn ligaments lie between the articular surfaces.

Some advise a dose of calomel, to be followed in eight hours by a saline.

To meet the indications mentioned, the ankle should be placed at rest, with pressure and cold applications at first; then massage and passive motion for a variable time, depending upon the extent of the injury, and in severe cases fixation on a splint, followed by the application of an adhesive plaster dressing. In the mild sprains the adhesive plaster dressing is applied at once. The patient is allowed to walk some on the foot within the limits of pain.

The adhesive plaster-dressing was introduced in this country by Dr. Virgil P. Gibney, of New York, in a paper published in the New York Medical Journal on February 16, 1895. He states that it was first used by Mr. Edward Cotterel of London.

The leg is first washed and shaved. For a sprain about the external malleolus the foot is held at a right angle, and slightly everted. A strip of rubber plaster twelve inches long and one inch wide is applied, beginning at the outer border of the foot near the little toe, and ending on the inner side of the foot about its middle, just under the plantar arch. The second strip is applied vertically, and passes from about the junction of the middle with the lower third of the leg, down alongside the tendo-achilles under the heel and terminating at a point just above the internal malleolus, but posterior to this.

The remaining strips are applied in the same way, each overlapping the other about one-half, until the malleolus and side of the foot up to the middle third of the leg is covered. It is well to reinforce just under the malleolus by strips passing crosswise, so as to give additional support to the part sprained.

The ankle is not completely encircled, so there can be no constriction. The dressing is applied in a corresponding manner for sprain about the internal malleolus.

Over the ankle thus strapped a cheese-cloth bandage is applied, which ensures the adhesion of the plaster.

If the toes are swollen, the whole ankle must be strapped. Every toe should be separately strapped before the ankle dressing is applied. The dressing may need to be renewed when the swelling recedes.

By this plan a slight amount of antero-posterior motion is allowed, just enough to prevent adhesions in the joint. Lateral motion is prevented, and so the torn ligaments are kept in apposition.

When the sprain involves the tarsal joint itself, or the midtarsal joint, and when the whole foot is involved, it is put up as follows: The first strip starts on the inner side of the heel, passes back of the heel below the external malleolus, over the dorsum of the foot, and terminates just under the ball of the great toe. The second strip is started just under the external malleolus, passes over the back of the heel, over the front of the foot, and terminates just under the outer side of the foot, near the little toe. The subsequent strips are applied overlapping upwards above the two first strips. Sometimes extra strips are applied up and down the tendo-achilles, the ends terminating in the sole of the foot.

Treatment in Detail.

1. In the mild form, where there is simply overstretching of the ligaments, with no effusion of blood, or very little, the condition can be estimated by the amount of immediate swelling and pain. The foot is bathed in cold water-though some men advise plunging it alternately into salt water as hot as can be borne, and cold water, for half an hour-to relieve the pain and check the hemorrhage.

The adhesive plaster-dressing is applied as described. The pressure of the plaster prevents any further effusion of blood. The patient is instructed to use the foot, and walk a little every day within the limits of pain.

2. In the medium form, which comprises most of the sprains encountered, where there is less or more rupture of the fibres of the ligaments, with less or more extravasation of blood into the joint and surrounding tissues, the foot is bathed in cold water, wrapped in several layers of cotton, with a firm roller bandage over them, elevated, and an ice bag applied for twenty-four or forty-eight hours according to the degree. This usually prevents any further extravasation of blood, and relieves the pain. This plan tends to subdue the inflammation and to lessen the subsequent synovitis.

The foot is then bathed in warm water. Gentle massage is given by the medical man, its object being to get rid of the effusion into and around the joint.

It should consist merely of gentle stroking in the upward direction, and it should be practised only for about one-quarter of an hour. At first it will probably be found that the lightest pressure causes the patient a good deal of pain, but as the massage is persevered with the pain becomes less, until at the end of the sitting the rubbing will be borne without complaint.

The adhesive plaster-dressing is applied, and the patient allowed

to use the foot within the limits of pain from the second day. The plaster may need to be renewed as the swelling recedes.

3. In the severe form, where there is extensive rupture of the ligaments, much contusion, and extravasation of blood into and about the joint, the treatment is the same as just described for forty-eight hours, but the limb had better be placed on a splint. The splint is removed daily and a warm bath given with massage and gentle passive motion by the medical man, care being taken that the ruptured ligaments are kept in apposition, as in a sprain about the external malleolus the foot is kept slightly everted.

This procedure is followed until the swelling has receded to a great extent, which may take from one to two and a half weeks. Then the adhesive plaster-dressing is applied, reinforced by one or two long strips like a stirrup, extending from below the knee on the inner side of the leg beneath the heel, over the outer malleolus, and finishing near the head of the fibula.

The patient is urged to use his foot some every day within the limits of pain. The plaster may be renewed as the swelling recedes -and the last dressing is generally allowed to remain until it loosens and comes off itself. Recovery is complete in five or six weeks.

The advantages claimed for this plan of treatment are: Early use of the foot, and consequent saving of the patient's time. Relief from pain and assurance of security, for the applied plaster furnishes support to the injured ligaments just where it is needed. Early disappearance of swelling, for the use of the foot and pressure of the dressing supplies the place of massage and passive motion. The ligaments are held in accurate apposition, and so secure and proper healing is assured.

DISCUSSION.

DR. F. N. G. STARR said the reader is to be congratulated first upon the choice of subject, and, second, upon the manner in which he dealt with it.

Many years ago the speaker used a large amount of wool tightly bandaged for 24 hours, and then applied what is now called the Gibney adhesive plaster dressing. The great thing is to avoid too. prolonged rest, and the next most important point is to avoid the possibility of flat-foot following.

The chronic untreated cases may give more trouble, but may be helped materially by the use of the hot air bath, followed by massage and subsequently by strapping.

DR. G. E. ARMSTRONG (Montreal), expressed his appreciation of

the thorough and carefully prepared paper. The treatment of these cases depended, first, upon a careful diagnosis. If only a strain of tendons and ligaments, rest for a few hours or days, according to the severity of the lesion. The application of ice inhibited swelling and effusion into the joint by lessening the blood supply through stimulation of the vaso-motor nerves. Later on heat applied locally promotes the removal of the swelling and effusion by dilating the blood and lymph vessels.

Another valuable aid is fixation in the normal position during the acute stage.

Of the value of strapping as practised by Dr. Gibney and Mr. Carter, it is of very great value. The strips should be so applied as to support the strained and injured tissues. In one case they should be applied on the inner side and in another on the outer side.

The removal of fluid from the joints, which has resisted other methods, by aspiration is desirable. The patient should use the joint as early as he can do so without pain.

DR. THOS. HUGH BALFE (Hamilton). In cases of sprains of ankle, it is always important to have complete rest and ice locally for the first 24 hours and firm bandaging, preferably by elastic bandage. It is also well to start passive motion early, with hot bathing, etc., to promote absorption of effusion into joints and to avoid adhesion of joint. I think it is well, if there is much effusion or hemorrhage, to aspirate, or if this is not done, not to allow the patient about too soon, and start early massage.

DR. GIBNEY complimented the reader of the paper on the excellent pathological detail, especially the point he made on the protrusion of a bit of torn ligament into the joint, thus explaining the persistent pain sometimes found.

He called attention to the necessity of conducting the case to an absolute cure, with complete restoration of function.

He took issue with one of the speakers on the statement he made about the necessity for rest for a week or ten days, believing that such a plan would result in impairment of function.

He called attention to the importance of an X-ray as a valuable aid to diagnosis, claiming that if a fracture or dislocation were thus eliminated in the diagnosis, that mild, medium and severe sprains were all amenable alike to the strapping treatment.