AIR-RAIDS AND FRACTURES SIR, —The after-treatment of fractures is summed up
in the word Rehabilitation, and I write as an orthopaedic surgeon to endorse the wise words of Mr. Robert Hyde (January 12th, p. 37), and to emphasise the need for rehabilitation in our hospitals.
The older methods of treatment did nothing to stop swell- ing of a broken limb, and it was usual to watch this occur for two or three days and then spend weeks or months rubbing it away and persuading stiff joints to resume normal working. Modern methods often necessitate the immediate enclosure of a limb in a plaster of Paris case, which diminishes the amount of swelling but makes massage impossible. Fixation of joints must be countered by insistence on full exercise of neighbouring joints and a return to full function of the limb at the earliest possible moment. This does not mean wait- ing till the plaster comes off in six weeks, but beginning sometimes within a day or two of the accident. The conunonest of the arm and leg fractures thus treated permit a return to certain occupations within two or three days, and that means full weight-bearing on the broken leg and maxi- mal use of the hand and fingers without crutch or sling.
Rehabilitation is the name applied to the methods of getting the patient back to full working capacity in the shortest possible time, and this should be an important department of every fracture clinic.
Complete segregation of all fractures in separate hospitals is an ideal that is impossible if 70 per cent, of all wounds are limb injuries. Some of the specialised fractures will no doubt be thus segregated, and it is to be hoped that the remainder will be nursed in separate wards in whatever hospital they may find themselves, but continuity of treatment and ade- quate facilities for rehabilitation should be provided in addition.
Until the war broke out I was in charge of a Fracture Clinic which was, I believe, the first in London to start a Special Rehabilitation Department, and Sir Malcolm Dele- vingue and his committee saw it at work. We evolved our own apparatus and soon learned how much can be done with a few pounds. A rowing machine, a resistance bicycle and a dart board formed the nucleus, and most of the other gadgets v. re either made by the hospital works department or pro-
vided by the kindness of volunteer helpers, who saw what was required and either made it or found the materials themselves.
It is an advantage to a civilian if he can have treatment that has an obvious bearing on his employment, and this brings us to work and play exercises. It is impossible to give a complete list because so much depends on the size of the room as well as on the available funds, but a carpenter's bench with a few simple tools, a sewing machine or a mangle, and a typewriter or piano, are good examples of the former. Heavier work, such as shovelling coal, can be found for the labourer, and almost everyone enjoys house painting. The play exercises include darts, indoor skittles or bowls and many adaptations of the weight and pulley. If space is ample there can be a ping-pong table or medicine ball, with their useful element of competition.
• Our staff consisted of a nurse who combined the work with that of the Fracture Clinic, but my ideal is a retired Naval petty officer or football trainer. He should be an enthusiast, blessed with that mixture of tact and authority which makes a good leader, able to keep the men keen and interested with- out the frequent obtrusion of medical supervision.
This work borders on that of the certified masseuse and occupational therapist (we had help from both), but their. special training is not necessary and the right man (or woman) will soon get such a department buzzing with activity.
Equipment costs £50 or less, and the results in return of function and confidence are astonishingly good.
Little seems to have been done so far in providing the emergency hospitals with massage and it is my earnest hope that every hospital will have a large Rehabilitation and a small Massage department.—Yours, &c., ERIC I. LLOYD.
80 Avenue Road, Regent's Park, N.W. 8.
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