The treatment of adhesions has already been dealt with under different headings. Here all that is necessary is shortly to recapitulate. Adhesions are composed of connective tissue, either the white fibrous or yellow elastic. The former are usually articular or peri-articular, and should be broken down by the surgeon whenever possible (see the following chapter). The latter are to be found in any extensive scar formation, and may be peri-articular. It is probably rare for this form of tissue to develop within a joint unless infection has been pronounced. Then the formation may be so marked that a fibrous ankylosis is present. Yellow elastic tissue calls for slow gradual stretching; sudden strain will fail to secure benefit and may serve only to irritate.

If attached to bone, no tension must be laid upon an adhesion until its bony attachment has been freed. There seems to be a sort of latent instinct in scar tissue which tells it that it is serving a definite purpose. If the tissue is attached to bone, this purpose is to inhibit movement, and, the more effectively to attain this end, it responds by development to the stimulation produced by any attempt to force movement. Thus the more we try to stretch it by movement the stronger it becomes. The first principle, therefore, in treating an adhesion with a bony attachment is to free it from the bone by manipulation, and to encourage active contraction of the muscles in which the scar is situated. In the meantime movement of the part is limited by splintage or other arrangement to such an extent that no strain whatever is placed upon the adhesion.

The principle of enforcing rest in the treatment of scar tissue is not fully appreciated. Many scars that fail to respond to massage treatment will loosen out materially if the whole part is kept at rest in a plaster splint. Thereby we may learn two principles in treatment: first, to beware of irritating any scars or adhesions, particularly if they are attached to bone; second, never to be reluctant to admit that a scar is not loosening properly, as there is an alternative treatment, viz., absolute rest in plaster. Needless to say, this does not apply to scars which have not yet healed, and it should be regarded as an exceptional measure rather than be used as routine. The loss of muscular power and the means for its restoration are dealt with in a subsequent chapter (see Chapter XVIII (The Re-Education Of Muscle).).

Fig. 96. - To show flexion of fingers by constant tension, the hand being placed in a glove.

There are four types of case in which fixation may prove beneficial. If the distal ramifications of a scar are still vascular, manipulation may tend to act as a counter-irritant and so set up a chronic hyperaemia, which ends in the formation of yet more scar tissue. Enforced rest allows devascularisation to take place, and loosening is then a comparatively simple matter.

There is no way in which the sources of trouble mentioned can be detected, except the failure of treatment to produce the improvement expected. Fixation should not be prolonged.

The second type of scar that may benefit from fixation is that in which, let us say, a wound has involved the whole of the dorsum of the foot, and skin, fasciae, and tendons are bound down in a single rigid mass to the metatarsals. Massage treatment is tedious, and often unproductive, whereas after a period of fixation the toes may begin to move of themselves. In other words, the tendons have succeeded in "pulling through" the scar. Massage can then materially hasten the restoration of function.

Fig. 97. - To show flexion of elbow being secured by use of the "cuff and collar." This shows how the elbow can be fully flexed and supination secured.

The third type of scar for which fixation may be given a trial is that which follows an extensive wound of the muscles. It appears as a deep sulcus on the surface, and movement of the muscles is a source of pain. If the muscles are placed at rest they waste, and then it may prove a comparatively simple matter to build up, as it were, scar and muscle together. Explanation is difficult, but the fact is undeniable.

The last type of scar that benefits by fixation is that which involves the joints or the peri-articular structures. The fixation is accompanied by constant tension, as when we try to straighten an elbow, finger, or knee on a splint, to flex the fingers by means of a glove (see Fig. 96), or the elbow by using the "cuff and collar" method devised by Robert Jones (see Figs. 76, p. 150, and 97).