The classical indications here are threefold: (a) Arrest of bleeding; (b) promotion of absorption of extra-vasated material; (c) prevention of adhesions and muscle-waste.

(a) With regard to the first indication, I do not think local treatment other than rest has any material effect. I have rarely seen the application of ice do anything but harm, although in an occasional case the instinct of the patient may lead to its being suggested. At all events, it is wise, if its application should be decided upon, to ascertain, especially in middle age and later, whether the kidneys are sound, for I have seen three cases in which extensive sloughing followed the continued application of ice in sprains with swelling in confirmed albuminuria, no precaution having been taken before the adoption of the treatment to inquire as to the possibility of renal disease: an excellent example of the way in which the apparently trivial nature of a case may lead to careless treatment of it. So far as the comfort of the patient is concerned, a fomentation, the hotter the better, has served my purpose best. Pressure during the increase of immediate swelling I do not use; it is as often as not distressing to the patient, and frequently produces oedema of the tissues below, if the part concerned is a limb. To sum up, rest of the part with very hot fomentations are the means I have come to rely upon.

(b) The increase of the immediate swelling having ceased, should the part involved be a joint, firm pressure by means of a porous bandage, such as crepe velpeau, firmly and evenly applied for twenty-four hours, followed by massage, gives the best and quickest results. The use of impermeable rubber bandages I have long since given up. Should massage not be available, skilfully-applied strapping is the best alternative, the frequency of its renewal being determined by the rate of diminution in the swelling. If the sprain be of the soft parts without joint complication, hot soothing compresses, such as the old and well-tried lot. plumbi cum opio, frequently changed, are more helpful than any other means, so far as I have seen, the pressure being increased as the swelling subsides. As soon as appreciable diminution in the swelling has occurred massage is indicated unless the part is abnormally hot to the touch.

(c) For the prevention of adhesions and muscle-waste, voluntary movements, massage, and passive movements rank in the order mentioned. Slight voluntary movements cannot be commenced too soon; splints, therefore, should in a general way not be used. The patient should, in fact, from the earliest moment amuse himself by seeing how far the part, if a joint, can be bent without permanent increase of discomfort. Massage should not, except in special circumstances, be delayed for more than twenty-four or at the most thirty-six hours after the cessation of increase in the local swelling. Passive movements should follow freely as soon as all heat has left the damaged part, whether the swelling be tense or not; and if the tension be rapidly diminishing gently passive movement may be used in spite of slight local increase of heat; but if the increase of the heat, which under these circumstances is sure to follow, does not subside within an hour or two, passive movement should be deferred for a time, although voluntary movements may be continued.

When an interval occurs between the receipt of the injury and the oncoming of the swelling, and in cases in which swelling, having followed directly after the injury, reappears after it has entirely disappeared or nearly so, the line of treatment mainly depends (1) upon the absence or presence of heat, and (2) in the case of joints upon the amount of tension.

In the absence of local heat, free massage and manipulation are indicated, combined with firm elastic (not rubber) pressure. In effusion without heat occurring in joints a fortnight or more after the accident, the possibility of syphilis or gout as contributing factors must not be overlooked. Iodides in some form internally are often helpful, especially when combined with free inunction of vasogen iodine locally. I know of no application which ensures the local effects of iodine without irritation to the same extent as this.

In well-marked haematoma in easily accessible soft parts coming on immediately after sprain, the course of the case may be greatly shortened by free incision and cleaning out of all clots, followed by immediate suture of the wound.