least no complaint is made. Unless pain be present a limp even, does not in many instances attract any attention and the number of painless deformities is great.

In acute disease the symptoms are more marked and an effort at least is made to ascer tain their meaning and significance. Ultimately life may as surely be destroyed by the chronic disease as by the acute, but in the beginning, the symptoms do not alarm and much progress towards the fatal outcome may have taken place before the physician is consulted.

At birth the more serious deformities are easily recognized and treatment promptly begun, but there are two conditions seen in orthopedic practice which are often overlooked; her nia and hematoma of tue sternocleido mastoid. The inguinal or femoral hernias at this time are small and if the baby is fat may not show cleary for some time after birth. Umbilical hernia rarely escapes observation as the toilet of the cord causes frequent examination of the part. The successful cure of a hernia by a truss depends on early diagnosis and in children many are thus cured.

Hematoma of the sternocleido mastoid may cause torticollis and early treatment prevents not only the necessity of future operative procedures, but makes it complete cure more certain. Torticollis, if uncorrected produces more than a mere twisting of the head to one side. Permanent changes may occur in the vertebræ and a curvature of the spine result. Permanent and serious changes in the growth of the upper extremity may follow, one side of the head, face and neck may have its growth interfered with and asymmetry result. Circulatory and nervous changes may interfere with nutrition and proper development of the entire individual. Congenital deformities of the spine cannot be detected unless the back is examined. Early and proper treatment of congenital lateral curvature depends on early diagnosis. Lateral deviations of the spine produced by faulty position or faulty manner of holding the infant may begin at a very early age and progress insidiously, but none the less certainly to serious conditions. Faulty school desks, faulty attitudes at school produce curvatures and the family physician must see to it that boards of education provide proper accommodations in these respects. The education of the public by the family doctor will lead to many such reforms.

The diagnosis of congenital dislocation of one or both hips is very rarely made until a considerable time after the child has begun to walk. If the gait is not particularly bad, many cases walk for long periods before it is suspected, yet the limp in a one sided dislocation and the waddling or rolling gait in the

double are easily made out. The position of the trochanter above Nelaton's line and the limitation of abduction without pain or symptoms of acute joint trouble make the diagnosis easy in typical cases. Proper treatment should be instituted early and delays until the child is advanced in years are dangerous.

ment.

Deformities from infantile paralysis or poliomyelitis come on very insidiously and can nearly always be prevented by proper treatIn the milder cases a faulty diagnosis may be made, in the severer cases this rarely occurs. The paralyzed limb is given electricity, is massaged, etc., yet it is rare that any thing is done to prevent the occurrence of club foot, knock knee, genu recurvatum, lateral curvature, drop wrist, etc. The parents will tell you that the deformity has been gradually increasing, that there was a time that the twisted and misshapen foot was simply a weak or frail member, and that the heel cord has gradually shortened and the club foot become marked. The orthopedic surgeon is rarely called to see a case until the deformity has occurred, but where he is privileged to see one in the early stages he can nearly always prevent the subsequent contractures and deformities, and the foot held in proper anatomical position tends to a greater degree of recovery in muscular power than does the one that is neglected and allowed to become deformed.

Those practicing a specialty unfortunately occasionally see cases, where no disease has existed, and yet there is extreme deformity due to faulty decubitus. Twice within the last few years, I have been called to operate on shortened hamstring muscles, because during the long confinement in bed of a patient ill with typhoid fever, the knees were allowed to be kept permanently flexed. Neither patient had any disease in the joints, and the simple precaution of straightening out the legs daily would have avoided this condition. More or less persistent flexion of the thighs may follow faulty position in a soft bed for a long time, and on several occasions it has been necessary to divide the thigh flexors to overcome the deformity. A hard bed and full extension of the limbs daily would avoid such results. To call attention to such deformities should suffice to prevent their occurrence. An early diagnosis of beginning knee flexion from faulty position will enable one to correct it by manual force where later on, operations on muscle or even bone may be necessary to produce the same result. After fractures, deformities that should have been prevented are occasionally found, notably the flat foot after Pott's fracture. With the increasing use of radiography many of the more difficult diagnoses in fractures and dislocations can be made sim

ple and correct diagnosis made and proper treatment instituted.

Rhachitis is a disease of childhood, except in rare instances. It is responsible for many deformities and their prevention should be carefully seen to. Early diagnosis of the disease is generally made but the parent who shows the bow-legged or knock-kneed baby to the family doctor is often comforted with the advice that he will undoubtedly outgrow it. Such advice, however, cures but few cases, and the deformities are allowed to increase until severe remedial measures are necessary before the limb can be straightened. All orthopedic surgeons have seen cases cured by the simple manœuvre of daily massage and bending of the soft bones, by the simple expedient of raising one or other side of the child's shoes and by braces. The writer is not aware of any case seen during the first two years of life where a cure did not result from mild measures, when they were intelligently carried out. To watch a deformity increase until it is necessary to break the bones to overcome it, is cer tainly not preventive medicine or good practice. Babies under one year of age, especially if heavy, should not be encouraged to walk. If any signs of rhachitis are present, delay having them walk until they are from fourteen to eighteen months of age and the limbs can grow strong enough to support the body weight without bending. Any one can easily satisfy himself whether a bow leg is increas ing or diminishing by placing the child on the back and with the ankles just touching, trace the outlines of the legs on a piece of paper. Allowances can easily be made at a subsequent tracing for the growth of the child. The im portance of early diagnosis in rhachitic deformities of the lower extremities applies also to other manifestations of rhachitis, especially the curved spine. These curvatures are essentially due to weakness and usually involve the entire spine. They are not sharp, like those in Pott's disease, but consist of a long posterior curve. The child bends forward and this makes the spinous processes prominent, at first the spine is freely flexible, but later it may become stiff, and herein lies the danger, because the curve may, if not corrected remain through life. The recumbent position, plaster casts or braces aided by tonics and massage, usually effect a

cure.

The bone affections of scurvy, may lead to serious results, if an early diagnosis is not made. The hematuria, often the first symp tom, the swollen and spongy gums, bleeding easily, the cachexia, the restlessness, sensitiveness and pain on handling, the fusiform swellings due to effusion of blood beneath the periosteum and the fever in acute cases usually

lead to a correct diagnosis. Prompt recognition means prompt treatment, and all know how readily the disease yields in most instances to proper diet and medication.

Cases of acute and chronic osteomyelitis are often referred to the orthopedic surgeon for treatment and the same is true of bone tumors. In all these conditions an early diagnosis is very important. In acute osteomyelitis death often occurs due to the delay to properly appreciate the meaning of the symptoms present, and to apply the proper remedies. In chronic osteomyelitis, located near the joints, much time is lost often by mistaking the condition for a tuberculosis or an arthritis and the condition may make much progress and require extensive bone operations, where in the beginning they would not have been necessary. The radiograph is a valuable aid to diagnosis in these cases.

Flat foot is a deformity that has been cared for up to recent times, in most instances by the orthopedic surgeon, but today the people, with the aid of the shoe store and instrument makers are treating themselves. To call attention to any abuse, usually means to bring down upon the writer abuse, but it is a fact that the abuse of flat supports is a growing evil. Many poor people buy these so-called supports, and suffer pain and discomfort while wearing them, only later on to discover that their home-made diagnosis was faulty and their ready-made treatment harmful. It is for the profession to say whether such abuse shall continue. Any diseased or abnormal condition of the body is worthy of the attention of medical men, and the prevailing custom of saying to a patient who says his feet hurt, that he should go to a given shoe store and buy a flat-foot support, without ever examining the feet, is certainly to be deplored.

Chronic affections of the joints whether tubercular or non-tubercular are frequently referred to orthopedic surgeons for treatment after the diagnosis is made, but how often is an early diagnosis made? I must say very frankly that the growth of orthopedic surgery has done much to disseminate knowledge of the symptoms of these conditions and that today early diagnosis is by no means rare, and that the general profession appreciate its im portance in joint tuberculosis. The symptoms vary with the joint affected and to go into them in detail would occupy too much time, but the importance of an early diagnosis is so essential to successful treatment in tuberculosis of the spine, the hip and the knee that a brief review of the symptoms of each will not be out of place.

Tuberculosis of the spine or Pott's disease is most frequent in the first two decades of

life. It usually begins very insidiously and unless the child is stripped and carefully examined, an early diagnosis cannot be made. But if these precautions are followed, it is usually easily made out before the kyphos or deformity occurs. Given a child that is peevish, restless, complains on being lifted or cries when handled, perhaps also cries out in the sleep, prefers to remain quiet, where for merly great activity prevailed, an examination of the spine is indicated. On testing the flexibility, spasm is found to exist, there may or may not be any prominence of the vertebræ noticed, there may be or may not be an abscess present in the pelvis, there may or may not be any signs of paraplegia, but if in addition to the spasm found by passive motion, one finds the same lack of motion present when the child attempts to pick up an object from the floor, and in walking holds the body stiffly, if you are not certain of the diagnosis in such a case, at least give the child the benefit of the doubt and command absolute rest in the recumbent position and make another examination a week or two later. If the symptoms still persist, a positive diagnosis can then be made or a consultant called in. To wait until the kyphos appears is not justifiable, it will come soon enough despite any form of treatment and although it may by proper and early diagnosis be kept down to a minimum degree of deformity or made to disappear, the writer has never seen a case that did not show any deformity sooner or later where the diagnosis was clear and unmistakably Pott's disease. To attempt to reduce deformity after it has occurred is justifiable and proper, but not by the violent methods proposed by Cabot. The best results. will be in those cases where the diagnosis was made early, although, unfortunately, some go from bad to worse despite any form of treatment.

Tuberculosis of the hip and knee and other joints also usually come on insidiously, and the early diagnosis is a large factor in their treatment. The traumatism of locomotion soon does damage to the inflamed parts and the deformity resulting from nature's efforts to immobilize the joint tends to produce contraction of muscles and other tissues about the articulation. In both, lameness is an early sign, and in both, pain may be referred to the knee. Night cries may be present when either joint is involved and limitation of motion due to spasm is an early symptom. In the knee the appearance of a synovitis is suspicious and one should always realize how frequently this condition is tubercular, syphilitic or gonorrheal. Guarded prognosis is therefore, essential even if the history clearly shows traumatism as a cause. In both the hip and knee one

has the advantage usually of being able to contrast the affected joint with the other which may be normal. Much valuable information can thus be easily gained. The reflex muscu lar spasm of joint disease is peculiar, it is constant while the disease is present, not intermittent, not exaggerated, but present no matter what motion is attempted. It may be present only at the extremes of motion, but if it can be made out, a positive diagnosis of joint involvement can be made. We may err as to the cause of the joint affection and thus make a faulty prognosis, but if spasm exists in the slightest degree, the patient must again be given the benefit of the doubt and the joint protected, especially so if atrophy of the mus cles or parts about the joints also exists.

Many applicants for the army and navy, the police and fire departments suffer from deformities that could and should have been prevented and had this been seen to in early life many now rejected would be accepted.

The education of the public is very important, it is a new and recent method of treatment, and like all new things will require in many instances much explaining. Many will see no necessity for regular and systematic examinations of themselves or their children, but we must keep at it and the family physician will become more important than ever and will guard against and prevent many conditions now common, but which should not exist, and to do this properly requires a knowl edge of orthopedic surgery.-New York State Journal of Medicine.

Special Abstracts

Under this heading we present from time to time abstracts of papers that seem especially worthy of note, on account of the intrinsic value of their subject matter, their topical character, or the official or other preeminence of their authors.

BURNS.

BY A. H. BARKLEY, M. D., Lexington, Ky.

Burns are the most frequent injury in civil life and cause the most agonizing suffering and often condemns the patient to a life-long mutilation of the most repulsive character.

Severity of a burn depends on the character and degree of heat, the length of time it is applied and thickness of the cutaneous surface.

Hot water, steam and metals are the most frequent causes.

Exposed surfaces as the face, neck, arms and hands are most often affected.

No difference between burns and scalds after long exposure. Scalds are more extensive in area and less deep as a rule and do not destroy the hair follicles.

Prognosis, first, as to life, and, second, as to the cosmetic effect and usefulness of a member. Much depends on, first, the age of a patient, as burns in children and old people are most fatal; second, as to those suffering from syphilis, tuberculosis, nephritis and other constitutional troubles, are most likely to succumb; third, as to the area and depth of burned surface, when one-third of the body is burned death usually ensues, however small areas may be followed by death due to shock and other complications; fourth, the location of a burn, as those of the chest are most fatal especially in children and alcoholics, those about the face and head are next in severity; fifth, complications such as cerebral, thoracic and kidney lesions render the outcome in any case doubtful. Thoracic and cerebral complications in children are out of all proportion even in slight injuries. Shock and sepsis are frequent complications and may follow any case of extensive burn. Burns are most severe when tight fitting garments are worn than when loose, as the heat is more directly applied. Certain fabrics protect the skin more than others; as silk and cotton offer more protection than wool.

Skin performs about 1-40 of the entire respiratory function. Thus a person 5 ft. 81⁄2 in. should have 2325 square inches of evaporating

*Abstract of a paper on Burns read before the Mississippi Valley Medical Association, St. Louis, Mo., October 12, 1909, by Dr. A. H. Barkley, Lexington, Ky.

surface. It can readily be seen how burns affecting large areas and depth would effect the health of an individual, as the skin plays an important part in the excretory function of the body.

Treatment should be general as relieving pain, combating shock and sustaining the patients' strength, and local as exclusion of air, thorough asepsis, preventing contractures, skin grafting and in total carbonization of a member even amputation may be necessary to save life.

Male, age 56, white, engineer, burned by hot water and steam. Patient is 5 ft. 10 in. and weighs 160 pounds. This was his weight at the time he was injured and has 19 square feet of skin on his body. Of this 10 square feet was burned, of which 4 square feet was of the third degree. Recovery was complete.

Interesting points in this case are area of skin burned, no contractures, no complications and healed without skin grafting.

GENITAL CANAL BLOCK FOLLOWING

NEISSER COCCUS INFECTION.*

BY CHARLES E. BARNETT, M. D., Fort Wayne, Ind.

With a number of photographs illustrating the pathology found in genital canal block, Barnett contends that sterility is not the greatest factor but that the pathology causing the block and following it, especially the retention cysts, are "nagging" the man's body continuously. One of the illustrations shows atresia of the sinus pocularis as the block. He believes that prostatectomy, unwittingly, frequently opens up the vesicular field for drainage. He considers that in the correction of this pathology the surgical question is a difficult one when the final results anticipate normal function. It is true that in some cases the cysts are emptied and the block removed. This relieves the symtoms temporarily, but the time may finally come when a recurrence will happen indicating that a thorough removal of the field that is pathologic is necessary in order to prevent a further extension of the diseased process, rather than to try to save a crippled canal surrounded by contaminated glands that will never assume complete resolution.

*Synopsis of paper read before the Mississippi Valley Medical Association meeting, October 12, 1909.

In a crowded audience, during the hush preceding the rendering of the first number on a concert programme, an old gentleman, rising slowly to his feet, challenged attention by ask ing if there were a Christian Scientist present. A particularly fierce-looking and determined old lady replied to the question by declaring herself a disciple of Mrs. Eddy. "In that case," bleated the old gentleman, "perhaps you will not mind changing seats with me, Madame, as I am sitting in a draught."

While not going to such extremes as the Christian Scientists do in the belief of the negation of all ills, Finkelstein, of Berlin, once an assistant of Heubner, has put himself lately on record in his belief that bad and contaminated milk does not cause diarrhoea in infants. declaration of the belief was founded on experiments in infant-feeding by giving to a large number of babies the ordinary grocery milk, which had been purposely incubated to increase the bacterial content. This milk was fed to the infants with no untoward symptoms ensuing. Either the certified milk depots are refinements which the public can safely dispense with as unnecessary, or Finkelstein has offended against the public health of the whole world by backing with the weight of his name an untenable statement. It is better to be oversure and to disregard the Finkelstein ukase, which later he may regret.

THE MUNICIPAL MANAGEMENT OF

TUBERCULOSIS.

Apropos of certain editorials that have appeared recently by authority of our representative society of medical practitioners relative to the municipal management of tuberculosis, an article by Dr. W. C. White, of Pittsburg, in the Johns Hopkins Hospital Bulletin for September, is worthy of consideration. Dr. White says, in part: "The tuberculosis question in any municipality has two definite problems to be solved: first, the medical problem; and, second, the sociological problem, which invades every portion of the social fabric of our country.

"The medical side is, of course, a most important factor, involving, as it does, such problems as pointing the way, making early diag nosis, the care of the already sick and the search of the still elusive specific cure.

"The medical profession, while it does wonders through many of its members, yet constitutes in itself one of the most serious problems of the sociological side of the tuberculosis situation. A large proportion of the profession are still ignorant of the fundamentals underlying our present conception of tuberculosis as a disease and the cure of the same. Many years must pass before the difficulty is eradicated by the production of more careful doctors through better teaching in our schools.

"The hospital where he is taught admits no tuberculous cases. In spite of this law, tuberculous cases are entered for operation, from mistaken diagnoses, for child-birth, through influence, etc., and the ordinary precautions of prevention and cure are neglected. Consequently, the embryo doctor is untaught; but, infinitely worse, the very place which should be a model for education in this line becomes a source of great danger of infection to those whose duty calls them there."

Is there not a considerable bit of truth in this statement? Is tuberculosis handled in an ideal manner in St. Louis by all of our medical practitioners? Is it handled in an ideal manner even in our municipal institutions? If so, then St. Louis needs no tuberculosis commission; no advice.

We are absolutely in accord with the idea that it should be the duty of the Health Department to control the management of tuberculosis, but, as Dr. White states in the article above referred to, there is a need of private and charitable organizations who must educate the inhabitants of the municipality to the point of accepting and carrying out this duty, and who shall provide for the many unfortunate consumptives who are not wholly destitute.

We are at a stage of the game in St. Louis,