The weight should never be great enough to cause pain, but just enough to tire out the contracted muscles, produce relaxation and thus relieve the pain. If there is any flexion deformity, the leg should be elevated on an inclined plane, extending from the buttock to the foot of the bed, high enough to allow the lumbar spine to lie flat on the bed. When that is done, the pulley must, of course, be at the upper ends of the incline. After all is adjusted, lift the foot of the bed about six inches to prevent the patient slipping down. The same rules apply when traction is applied to the head for cervical or dorsal disease of the spine, except the inclined plane will not be necessary, and the head of the bed instead of the foot must be elevated. It is essential, too, in head traction, that the halter should be so adjusted that traction will be equal upon chin and occiput, or the patient will be uncomfortable. The patient should lie flat, without a pillow under the head, but with a thin narrow pillow, made of a folded woolen blanket, under the diseased vertebræ.

When the pain and spasm are relieved, and the affected joint can be put into the proper position for permanent immobilization, the best fixation dressing for the first few months is plaster-ofparis. It is easily procured, and, with a few precautions, can be put on anywhere, by any physician, so as to be perfectly comfortable for the patient, and it can be made to immobilize any joint more effectively than the best mechanical apparatus.

Plaster-of-paris should never be put onto the bare skin nor over absorbent cottton. The best protection is a garment of snug-fitting cotton underwear covered with a layer of sheet wadding, bandaged on firmly with a cotton roller-bandage. For the hip, the cast should extend from the tenth rib to the toes; for the spine, it should extend from the sternoclavicular articulation to just above the trochanters. If the disease is above the seventh dorsal vertebra, the neck and chin must be included. These casts should be changed about once a month, to inspect the diseased joints and care for the skin. When all signs of progression of the disease have disappeared, and it seems evident that the process of repair has begun, it is safe to use some mechanical apparatus, though I believe that in the hands of one who is not skilled in the use of braces, the plaster-of-paris cast is safer throughout the entire course of the disease; for the simplest brace will get out of order, and the parents become careless in its adjustment, and unless a brace holds the joint firmly fixed all the time, it becomes a burden instead of a brace, and does more harm than good.

The simplest and most efficient spine brace is the old anteroposterior leverage brace designed by Dr. Fayette Taylor. It must be made from accurate tracings of the spine and pelvis made with the patient lying prone, and then must be carefully adjusted after it is finished, so that just the right amount of pressure is exerted on the transverse processes of the diseased vertebræ, as it must be remembered

it is a leverage brace and when it ceases to act as a lever it is useless. The so-called crutch braces, made with an upright fixed to the pelvis band, bearing crutches which lift up the patient's shoulders, are useless, unless the spinal uprights act as levers, and are constructed on an erroneous idea. The shoulder girdle is so loosely attached to the thorax that any pressure exerted by these crutches in the axilla sufficient to take any of the weight off from the diseased vertebra would be unbearable to the patient. For the same reason all plaster jackets should be trimmed out under the axilla to allow the arms to hang normally and move freely. It is hyperextension of the spine that is aimed at in all apparatus for Pott's disease, not to lift the superincumbent weight, for by hyperextension the weight is shifted from the bodies of the vertebræ to the articular and transverse processes, and the pressure on the affected vertebræ is thus relieved and with perfect comfort to the patient.

For the hip there are two braces that have given great satisfaction in my hands. One, the Judson long hip splint, is to be used with traction when the disease is progressive and when it is desired to let the patient walk without crutches. The other is the Thomas hip splint, which necessitates the use of crutches the same as a plaster cast. The first is useful when the patient can be seen at least once a month, and where the parents can be made to thoroughly understand its principle and depended upon to keep it accurately adjusted. The second is useful to maintain a fair amount of fixation in cases which are beyond the progressive stage, or where the patient cannot afford the more expensive traction splint.

ANTISEPTIC INJECTIONS.

For several years the injection into the affected joint and the surrounding tissues of antiseptic solutions was a favorite procedure of some surgeons. The antiseptic most frequently used was iodo form, suspended in glycerin or oil. Like others, I tried it in a long series of cases and have discontinued it. I remember just one case, a knee-joint, where I thought it was helpful. I know that the idea has been very generally accepted that iodine has more curative or inhibitive effect in local tuberculous infections than any other drug, but, after fifteen years' experience and having given it faithful trial in various forms, I have come to the conclusion that I want to be shown, for I have never seen any evidence of it myself.

Moreover, I do not believe it is a rational surgical procedure to inject an insoluble substance blindly into a tuberculous area in the hope that it may hit a spot where it may do some good. Certainly if we stop to remember that in nine cases out of ten the primary focus of infection is in the bone and not in the joint, and that long before the joint becomes invaded and we get ready to inject, the disease has spread in various directions through the joint struc

tures accompanied by grannulation tissue-if, I say, we carry that picture in our minds, we should certainly realize that a blind injection of iodoform, or any other substance into the joint, has about one chance in ten thousand of ever reaching the deepseated foci which are causing the trouble. And, unless we can reach them what possible good can the injection do? There is just one class of cases in which I believe antiseptic injections may be useful and I frequently use them, but I do not use iodoform. Those are the primary synovial cases, seen in young adults (twenty to forty years of age) and beginning as a subacute synovitis, with gradual swelling, little or no pain and slight disability and limitation of motion. For such cases, if seen before the disease has penetrated the joint structures and invaded the bone, I inject a mixture of three per cent. of formaldehyde solution in olive oil. Formerly I used glycerine instead of olive oil, but glycerine is so hygroscopic and irritating that I abandoned it for olive oil. My experience with this has not been sufficient to warrant definite conclusions, but it seems to me that some cases have improved more rapidly than others have without it.

BIER'S OBSTRUCTIVE HYPEREMIA.

My experience with the so-called Bier's treatment or passive hyperemia has been disappointing, but I do not charge that to the inefficiency of the treatment but rather to the inefficiency of the use of it. I have only used the rubber bandage for producing the hyperemia and have had no experience with the vacuum apparatus. Some cases may have gotten well sooner than they would without it, but the improvement is so slow that many patients get tired of applying the bandage two or three times a day. for three or four hours and few are willing to come to the office daily for a protracted period to have it applied. Those who have used it most persistently and accurately claim good results.

X-RAYS.

I shall dismiss the X-ray treatment of tuberculous joints by saying that personally I have never seen any benefit from it nor have I known anyone who has. During the early enthusiasm over the X-rays, many cases were reported of improvement and cure, but I tried it conscientiously in quite a number of cases without seeing any improvement and gave

it up.

TUBERCULIN INJECTIONS

What I have said about X-ray treatment might with a little modification be said of tuberculin treatment. When the interest in Wright's opsonic treatment was at its height, two years ago, I had quite a large series of cases given the treatment with tuberculin after Wright's method. It was done by expert laboratory workers, who were trained by a colleague, who had spent some time with Wright in his laboratory, and the cases were nearly all patients in St. Luke's and Cook County hospitals,

where they could be kept under constant observation. In a few cases the rate of improvement seemed more rapid than it would have been by mechanical and surgical measures alone; in the great majority of cases it apparently in no way influenced the progress of the disease, while a few cases seemed to be made worse rather than better. The fact that it has been so generally abandonedat least in America-after the enthusiasm which it first excited, seems to me to be a sufficient commentary as to its value.

All I shall say about hot air, incandescent lamps and other similar procedures is that I have not been enough impressed with their possible value to even try them, and I know of none of my colleagues, who see and treat large numbers of tuberculous joints, who have.

COMPLICATIONS.

Although I have already extended my discussion of this subject over more time than I originally intended, I should feel that I had omitted the most important and most interesting part of it if I did not say something about the treatment of the more important complications, as they oftentimes constitute the most serious part of the disease, and cause both patient and surgeon much anxiety. The most important of the surgical complications are tubercular abscesses, tubercular sinuses and the paraplegia of spinal disease.

Tubercular Abscesses:-We have all of us been. for so long imbued with the idea that all abscesses should be opened and drained as soon as fluctuation is detected that we have failed to see that a socalled tubercular abscess is not an abscess at all, and that the rule did not apply. We have been a long time learning that a patient with a simple tubercular infection, though he may have an abscess as large as his head, is very fortunate and has infinitely a better chance of recovery than a tuberculous patient with a mixed pyogenic infection. added to his tuberculosis. We, who would never think of opening an uninfected knee-joint or cystic tumor except under the strictest asepsis and have always closed such wounds immediately for fear of infection, have cheerfully opened sterile tubercular abscesses and stuck in a drain and condemned the patient to dress an infected sinus for months or years and thought we did good surgery.

I have seen scores of patients with large abscesses, so-called, who had little or no temperature, gaining weight, and doing well in every way and after the abscess was opened and drained have seen them lose weight, the temperature go up, appetite fail and the patient grow worse-and possibly die from septic infection. And I have quit.

I believe there are just as positive indications for opening tuberculous abscesses as there are for any other aseptic operation, and that they should be opened only when those indications are present. While I have opened many such abscesses in the

past three years, I have never drained them, and my results have been so much better that I have simply wondered why I ever did it before.

Indications.-When a tuberculous abscess is so situated or is so large as to interfere with mechanical treatment, it should be evacuated.

When it is burrowing so rapidly as to threaten the integrity of subcutaneous tissues to any considcrable extent, it should be evacuated. When the patient has a persistent high temperature, with indications of toxemia and is doing badly, if an abscess is present, it should be evacuated. If the abscess shows signs of probable rupture, it should be evacuated.

Technique. I never attempt to evacuate such an abscess by aspiration or by puncturing with trocar and canula because both methods are irrational and inefficient. Anyone, who has ever seen the contents of a tubercular abscess, containing cheesy masses of various sizes, flakes of coagulated fibrin and often small bony sequestra, must realize that such can never be evacuated through a trocar, and those are just what must be expelled to do any good.

I make an incision large enough to admit my finger, not at the most dependent site, through healthy skin alongside instead of over the abscess. The contents are gently expelled and the cavity is gently washed out with normal salt solution, sterile water or some mild antiseptic. When the water returns clear the fluid is all pressed out gently, the edges of the wound sponged with bichloride and tightly closed with deep sutures. Then a large compress is snugly bandaged on so as to keep the walls of the cavity in contact as much as possible and the patient is kept in such a position as to prevent tension upon the line of incision until after it has healed. By this method we relieve the tension inside the abscess, allowing the walls of the cavity to collapse without infecting the cavity. I have become convinced that it is impossible to dress an open wound, leading to such a cavity, for more than a week without its becoming infected even under the most ideal hospital conditions. Sometimes this method of evacuation disposes of the abscess permanently, but usually they fill up again, although not so full. They may have to be evacuated several times, each time becoming smaller, but it is far better for the patient to have it done a dozen times, as it can be done with local anesthesia without pain, than to have it drained once and become infected.

Sinuses. What to do with old infected sinuses, leading to tuberculous bone foci, often discharging for months or years, has long been a puzzle to the surgeon. Constant irrigation with antiseptic solutions certainly does no good and I believe does harm. Curettage is worse than useless, as it simply exposes an increased area of raw surface to infection. Open incision is futile unless it reaches and removes the foci of infection. So for many years I simply let them run, keeping the skin clean

and depending upon Providence and the patient's resistance to finally close them up, and if the patient lived long enough they usually did.

But two years ago Carl and Emil Beck, of Chicago, suggested a procedure, which, while it has distinct dangers and limitations, seems to be more useful in selected cases than any other treatment I have ever tried. I refer to Beck's bismuth paste injection. It was originally used to fill sinuses and fistulous tracts when radiographs were to be made, so as to show the extent of the infected area, the bismuth being impenetrable to the Roentgen rays. They noticed, however, that sinuses so treated often closed more rapidly than usual and so began experimenting with it for that purpose. Their results inspired them with much enthusiasm and led the profession to hope that a sure and easy way of closing old sinuses had been discovered. The procedure is beginning to find its exact status now, and I believe it is useful and has come to stay. Technique.-The sinus is first dried out as thoroughly as possible with gauze on a probe. the following mixture in a melted state is injected with a blunt pointed syringe until no more can be introduced: R Bismuth subnitrate, 15; white vaseline, 30. Mix.

Then

This is injected at a temperature of about 105° F. and soon hardens at the temperature of the body. If the sinus is discharging much, it will usually be extruded in a short time. Usually within a week or ten days the discharge has diminished and then they use the following: R Bismuth subnitrate, 15; soft paraffine, 5; white wax, 5; white vaseline, 30. Mix. Melted and introduced in the same manner. This, however, forms a more solid mass than No. 1, and remains longer in the tissues. But as it disintegrates and is expelled the discharge ceases and after a few injections at intervals of one to two weeks, the sinus finally closes up. In some cases, I have had to make but one injection, in others repeated injections had little effect.

The danger lies in damming up the discharge in cases where there are cavities with small openings, and poisoning from the bismuth. I have had several cases in which, following each injection, the discharge would stop suddenly and the patient's temperature go up with all signs of intoxication, and only after the paste had been expelled and a large accumulation of pus evacuated would the trouble stop. Emil Beck has himself reported several cases of bismuth poisoning, and I have seen four with two deaths, so I believe it is decidedly unsafe to inject large amounts of the paste into cavities where it may remain and become absorbed. Beck believes that the bismuth has a distinct curative effect upon the disease. I believe its whole value is mechanical. It separates the surfaces of the sinus and prevents the constant maceration of the weak granulation tissue in moisture and gives it support while it is undergoing organization; thus furnishing a nonabsorbable superstructure behind and upon which

the fibrous tissue can build. I believe a paste containing any other non-toxic and non-absorbable substance would do just as well and I purpose experimenting with several this winter.

Potts' Paraplegia.-Paresis or paralysis affecting the lower extremities-the so-called Potts' para

plegia-occurs in about 10 per cent. of all cases of tuberculous spondylitis. It may occur early in the disease, especially when the mid-dorsal spine is affected, but, as a rule, it is a later complication. It is due to an extension of the disease backward into the spinal canal, and pressure upon the cord by the exudate and the pachymeningitis which results. It may present any degree of paralysis, from weakness and inability to control the legs to complete paraplegia, involving the bladder and bowels. Sometimes, especially in dorsal disease, the spastic contractions are so constant and severe as to be very distressing to the patient. If the patient is promptly put to bed, with traction on the head, as described above for the treatment of the pain and muscular spasm, and kept continually in bed long enough, the paralysis usually disappears. It requires from six to eighteen months usually, but I have never seen a case in which recovery from the paralysis has not occurred where the treatment was kept up for sufficient length of time.

DISCUSSION.

DR. H. R. ALLEN: I am always glad to attend a meeting where an orthopedic paper is read, and Dr. Porter has contributed a most interesting paper and clinic. He has gone over the various forms of treatment, including injection of iodoform emulsion, glycerine, bismuth paste, and other drugs, and, like all men of quality, comes back to the most important phase, the tuberculous joint, and shows us that after all we are dealing with a mechanical situation. From time to time in the future we are to read of this and that "sure cure" for tuberculosis. I am as anxious for an absolute specific for the tubercle germ as any other living man could be, but if to-day we had an absolutely reliable specific for the tubercule germ, it would still only play one part in the cure of tuberculous joints.

Remember always that an attack upon a mechanical structure calls for mechanical treatment. If the skeleton inside the body is rendered deficient, it is necessary to apply an outside skeleton which will perform the duties that the inside skeleton should fulfill, until the inside skeleton is able to perform its own normal duties. Dr. Porter has presented to us in clinic a girl with an advanced tuberculous inflammation of the hip joint. It is chronic in form, chronic by many years, presenting many interesting mechanical features that many doctors fail to appreciate.

Gentlemen, the femur is like an inverted tent. pole, the muscles attached to it and the pelvis being like guy ropes that are attached to the pole and to the circle of ground surrounding it. When a joint is infected by the tubercle germ, the muscles controlling that joint deprive the joint of its full range of mobility. In other words, the loss of complete motion is a diagnostic feature of joint in

fection. If the muscles of the thigh arrest motion, they do it by contraction. If the muscles contract, they drive the head of the femur tight against the superior wall of the acetabulum.

Tuberculous hip joint produces two conditions. One is the presence of the tubercle germ, and the citing cause. We have no specific for the tubercle other is the presence of some non-tubercular exgerm, consequently we direct our attention toward the non-tubercular exciting cause. This is found to be mechanical. It is the pressure of one diseased bone against another. This can be relieved by efficient mechanical apparatus. I do not refer to plaster dressing, or to weights and pulleys, as each of these guarantees a prolonged, tedious course of treatment, followed by too high a per cent. of failures. Plaster-of-paris is a thing of the past; it is a thing of the past among able mechanics in our profession.

It is necessary in the treatment of these cases to put an extension sole beneath the well foot. I believe it is almost essential to add to this extension an ankle brace which extends half-way up to the knee. I know of no one else who recommends this treatment. However, it appeals to me as rational, and I believe it will appeal to you as practical. You are all quite familiar with sprained ankles, and you all know how much more frequently ankles are sprained than knees are sprained, the knee being almost entirely a lateral movement, while the ankle is provided with much lateral movement and yet permits the foot to rotate in or out to a limited degree. Now, if the ankle, now two or three inches above the ground, is raised six or eight inches above the ground, the leverage of the extension sole predisposes the patient to injury of the ankle joint, this supplying one-half of the formula for tuberculosis of the joint. The tubercle germ is already active in the system, and is only awaiting the non-tubercular exciting cause. It appeals to me, therefore as rational to protect this joint against accident.

DR. A. D. WILMOTH: I think this is such an important subject that it ought to have more discussion than it has received. I was glad to hear the doctor emphasize one thing, and that was that you must have continued fixation of the joint. That is the cause of just such cases as was presented here this afternoon, and of crippled boys and girls all over the country-the fixation of joints that has not been kept up long enough.

I want to emphasize another thing, and that is that in the majority of these cases, in their incipiency, you should put them to bed, where you can fix the joint. That means not three or four weeks in bed, but three or four months, and then treatment after that, and holding the joint fixed.

One point that was mentioned by Dr. Allen in regard to plaster-of-paris. I do not want to uphold plaster-of-paris, but I want to correct one statement that it gets loose within a week or two, due to atrophy of the limb. It is loose the next day after you put it on. Why? Not because of shrinkage of the limb, but because the plaster shrinks as it dries.

You must have fixation for a long period if you expect to do these cases any good, because, after all, we must depend on nature to cure them; so we must give her the best chance possible.

D

SANITATION OF BARBER SHOPS.

BY G. A. PERSSON, M.D.,

MT. CLEMENS, MICH.

URING the last two years several cases of skin diseases have come under my observation, where there was good ground for the suspicion that the infection originated in the public barber shop. Going over some records, I find that among these cases there are three in which the patient can recall the particular time and place of infection, making its source conclusive.

CASE I. Mr. R., aged twenty-eight, coachman, usually shaved himself. One day, while in a barber shop to have his hair cut, the neck was shaved, and after leaving the shop he noticed an abrasion behind the left ear. A physician's attention was called to it, and notwithstanding continual efforts on his part it failed to heal. Some time later the patient noticed sores in the mouth, and he was advised at once to go to Mt. Clemens for the baths. The Wasserman reaction for syphilis, which in this case was very pronounced, together with the characteristic mucous patches in the mouth, readily established the identity of the infection.

CASE II. Mr. B., aged twenty-eight, farmer, states that on a certain day, about one and one-half years previous to his first visit to my office, and in a certain barber shop, he was shaved; on the following day he noticed a pimple on the right side of his face. It formed a pustule which opened and discharged very slightly, but never healed. About six months later it started to spread. The staphylococcus aureus was isolated in practically a pure culture from the infected part.

CASE III.-Mr. T., aged forty-nine, druggist. At the age of twenty he recalls how he noticed a sore and itchy place on the back of his neck, the next day after being shaved in a public barber shop. This condition continued regardless faithful applications of lotions and ointments received from the family physician. The infection spread very slowly. When I first saw this patient the entire surface of the body, except the face and scalp, showed infected areas. This patient's hands were much infected by rubbing and scratching the infected parts. The palmar surface is found particularly involved, the patient being practically unable to use his hands.

Up till the time of the above experience I had always taken for granted that any man could avail himself of the services in the public barber shop with impunity, but having been forced into a doubtful state of mind, I decided to solicit the opinion of medical men from various parts of the country regarding the public barber shop as a probable source for infections in skin diseases of the face and scalp.

To my inquiring letters I received courteous answers, containing differences of opinion. The view was held by a large majority-I may say by all who had given the subject any thought-that many affections, not only local skin diseases, but also constitutional conditions, such as syphilis, were con

The secretaries of State boards of health throughout the country were appealed to for data, and it was learned that many of the States had some law or ordinance pertaining to the regulation of barber shops. Other States were advocating the passing by the State legislature an appropriate act for the purpose of giving the health authorities power to act in this matter. Several of the secretaries in States where such law was already in force complained that it was difficult to apply this ordinance. I quote from one communication as follows:

"The general demand of the public for proper conditions of health is rapidly forcing proper cleanliness upon the barber shops in this State. Our State health law covers almost all unsanitary conditions, in that it gives sanitary authorities power to do all that is reasonable and necessary for the protection of the public health. This has been sustained by the Supreme Court. Of course, it takes money to carry on warfare, and we are only limited in our work by lack of appropriation."

From another letter I quote:

"We have found the condition to which you refer an almost universal one. In this State we have passed a law providing a State board of barber examiners, and this board formulates the rules and regulations under which every shop must be conducted. Since doing this we have had far less barber shop infections, but it is difficult to entirely stop them."

The senate bill recently passed by the legislative assembly of North Dakota is a fair sample of the general State law on this subject.

SANITATION OF BARBER SHOPS, ETC. (Senate Bill No. 271, Leutz, 1909.)

Be it enacted by the Legislative Assembly of North Dakota:

SEC. 1.-Barber's Tools Disinfected.-Registered barbers or barber's apprentices, and all persons engaged in hair dressing and manicuring, must disinfect all tools used in the performance of their profession before they are brought into direct contact with the person of any of their customers. disinfection must be carried on in a manner approved by the Board of Health of the State of North Dakota.

This

SEC. 2.-Violation of This Act, How Punished.Any violation of this act shall be punished by a fine of not less than twenty-five dollars nor more than two hundred dollars.

Approved March 15, 1909.