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cosuria after ingestion of 100 grammes of grape sugar, whereas out of twenty unselected, healthy persons only two gave this positive result.-Practitioner, p. 95.

SUTURE OF THE PATELLA FOR FRACTURE.

Dr. Westbrook (Brooklyn Surgical Society) presented a patella recently sutured for fracture.

This was a specimen of a fractured patella which he had recently sutured, and which he removed from a patient who died from alcoholism. He came into the hospital with a fresh transverse fracture of the patella, with considerable separation of the fragments, and moderate reaction in the knee joint. The speaker had operated after a week and found the separation to be low down in the patella. The fragments were drilled and united by several threads of chromicized catgut. The patient did perfectly well as regards the wound, but after a week or so he began to develop symptoms of wet brain, and slowly failed, and died on the thirteenth day, so that the speaker had an opportunity of removing the patella. He found no evidence of the catgut remaining at all; it seemed to have entirely disappeared. I had supposed it was chromicized catgut and that it would certainly last in the tissues for a greater length of time than thirteen days; but the catgut had disappeared, whether it was chromicized or not, and the union was good. It seemed to him that the simple suturing of a patella, after drilling, with plain catgut or chromicized catgut accomplishes very well the object required, i. e., simply to keep the fragments in good apposition until union has occurred. One of the main objects of the operation is to remove all fibrous tissues which fall down between the fragments of the patella, so that osseous union may occur. It is a very easy thing to get the fragments in apposition, especially if the leg is well extended and the foot somewhat elevated, and it is not necessary for that purpose to use anything as strong as wire and besides the wire has the additional disadvantage of possibly setting up irritation later and requiring to be removed. The only advantage in using wire is that it may cause a stronger union during the first few weeks until very firm osseous union has occurred, and permit freer passive motion to begin with. Some have flexed the leg moderately as early as the second week. The speaker had massaged these knees as early as the second week, where firm union had occurred, but had not permitted flexion so early, employing only lateral motion of the patella in the massage. This patella would certainly admit of that. Many surgeons are simply suturing the capsule, and not drilling the bone at all, feeling that there is less likelihood of infecting the knee joint and that drilling is quite unnecessary. He had not done it himself, but he had seen others approximate the fragments in that way, yet not getting the best approximation; the superior surfaces of the patella would come well together, but the surfaces toward the knee joint did not approximate so well. That may be a very good way of treating patella fractures, but to his mind it is a very simple matter to drill the two fragments and one can do it without putting the finger into the joint at all. Rubber gloves should be used at such a time, and only sponges in holders need come in contact with the joint. He also put five chromic catcut sutures in the capsule in this

case, bringing the tissues well together. There is fair union here at the end of thirteen days, which would certainly permit of free lateral massage, but of course he would hardly dare to attempt flexion, even in a slight degree.

As regards the ultimate advantage of having the patella united by silver wire, in the matter of preventing a late re-fracture, he thought most authorities feel now that there is no especial strength added by the presence of a wire; although in the earlier stages, before firm osseous union has occurred, the wire might very well make the union more firm so that active massage might be carried on with more assurance.

Dr. G. R. Fowler said that the fact that such a result could be obtained in so short a time is almost a revelation to us. It simply emphasizes one point in his mind, and that is, that even the softest suture material, when the surfaces of the patella are brought together after the removal of the fibrous fringes which fall upon the surfaces after fracture, will suffice, provided the surfaces are once brought into apposition.

He mentioned the use of the suture passed through the bone after drilling, in comparison with suture of the capsule. If the anterior portion of the capsule only is sutured it goes without saying that the edges on the posterior surface may be spread apart, still, if the precaution is taken to pass a strong suture upon the inner and upon the outer side of the patella in such a way that the posterior as well as the anterior edge is brought in contact, the objections to simple suture of the capsule can be largely removed. A transverse section of the patella at almost any height will show either an ellipse or a modification of an ellipse upon the section, and a moment's reflection will show that if the suture upon either end or both ends of the fracture can be so placed as to bring the bearing along the center of the ellipse, the posterior as well as the anterior edges will be brought in contact. He said this simply because it is desirable to avoid drilling the bone whenever it is possible. As a result of drilling traumatism is added, increased opportunities for infection occur, and the necessity for a further and unnecessary handling of the fragments. arises.

The employment of wire has largely gone out of use. When we consider that the strength of the chain is its weakest point, that the structure of the patella itself will bear very little strain, and that, if the strain is sufficient to break a good sized chromic catgut or stout kangaroo tendon suture, it would be sufficient to tear the wire through the bone itself, we will see little necessity for the use of wire. Early lateral passive motion of the patella combined with massage should be employed. Massage itself promotes very greatly the rapid union of the patella fragments, as has been repeatedly shown. It has also sufficed in some cases to procure good bony union of the parts without any other treatment. When this early passive motion is instituted, either chromic gut or chromicized kangaroo tendon or simple kangaroo tendon, or even plain catgut will bring about an exceedingly good result, particularly if the precaution is taken, as mentioned by Dr. Westbrook, to produce hyperextension of the limb and elevation of the entire limb so as to relieve the strain on the parts through the quadriceps extensior femoris. After the first ten days it is best to abandon the splint

and have the patient make involuntary or even voluntary movements. This is conducive to an early functional result, the dressings themselves affording sufficient restraint without the posterior splint. In the old days we kept patients on the posterior splint too long, intra-articular adhesions formed and the functional result was greatly hindered by the too prolonged use of the splint. He had even gone so far as to advocate that the patient shall walk early on the limb instead of waiting the proverbial six weeks. It is better to cautiously commence, from two and a half to three weeks after the operation, to make use of the limb without the splint, or with the splint at earlier periods.

One of the most successful cases in his experience was that of a milkman who had to go about and serve his route on the second day following the accident. In this In this case a simple posterior splint consisting of a piece of light "strap iron" and the old-fashioned retentive apparatus was employed. The result was one of the best he had ever seen where actual suture of the patella was not done. Dr. M. Figueira had had one case that impressed him very strongly. He had removed the splint on the second day and the man went to make a step and slipped and refractured the patella and had to stay in the hospital another six weeks. He thought the best way is to have a splint that will allow a certain amount of motion but yet that will, in case of an accident, check the bend of the knee and refracturing of the patella; allow a certain amount of flexion to a certain angle and yet with a check, so in case of a slip it will avoid the tearing of the fragments apart as it did in this case.

Dr. Warbasse said that the important thing accomplished by the operation is the removal of the fibrous tissue and clots intervening between the fragments.-Brooklyn M. J.

SOME TRAUMATIC NEUROSES AND THEIR

TREATMENT.

BY J. SHERMAN WIGHT, M. D.

The local symptoms which follow nerve wounds have an interest belonging to no other lesions, and may occur whether the nerve has been severed or has received a contusion. Recovery takes place in general in proportion to the number of fibers cut or the severity of the contusion, since the bruising may amount to the section of some or all of the fibers of the nerve in its subsequent history. Electrical injuries have their distinctive symptoms, and, while we are obliged to admit some direct action on the cells, yet it is certain that the force of the shock comes on the nerves.

Case I: Mrs. B., age fifty-seven years, came to me complaining of a hard lump in the left axilla, in site of the scar of an operation which I had performed two and onehalf years before, for carcinoma of the breast. I dissected out this mass. Her early convalescence was marked by severe pain in the axilla radiating down the arm. Redness appeared over a considerable area of the thorax and extended beyond the posterior axillary fold. Later an edema developed, marking the height of the neuritis. This was due to injury to the nerve supply during the last operation. The wound was dressed dry, morphine was used to control the pain, and the arm was kept im

mobilized for three weeks, when the vascular tone returned and the edema disappeared, leaving slight tenderness over the area involved. I saw her a year later. She had had but two attacks of pain, of a burning character, with slight redness and edema. This lasted about eight days. Examination showed only slight tenderness, and muscular development about normal.

Case II: I. R., twenty-seven years, riding in a carriage in collision with a car, received a contused and lacerated wound of the right temple and forehead, involving the areas of distribution of the first division of the fifth nerve, through the supraorbital, supratrochlear and lachrymal; second division of the fifth nerve, through infraorbital and temporo-malar; third division of the fifth nerve, through auriculo-temporal. Repair took place with scarring. I saw her one and a half years later, and found her suffering with severe neuralgia of a remittent type, exacerbations corresponding to local blushing, and elevation, the latter amounting to edema, and recurring every four days. Asthenopia was recorded, and the height of the attack found her with loss of the power of accommodation of the right eye. Here, as in Case I, was a weakening of the trophic influences of the nervous centers on the part supplied by the disabled nerve branches. Temperature, recorded locally, gave 2 degrees higher register than the surrounding areas. Metabolism was more active, and the power of resistance of the cellular elements was reduced so as to furnish, as in Case I, a fertile field for infection: This teaches that every incision should be made, as far as possible, parallel to the course of the nerves, equal in importance to every effort to avoid prolonged handling of the tissues during an operation, both of which precautions go far toward preserving the vital integrity of the cells.

Case III: Mrs. K. received a compound comminuted fracture of both bones of the leg. The projecting ends of the fragments were resected, and union took place after the delay of some months. Swelling was slight, and pain followed long use in walking. I saw her twenty-four years later, when pain was constant, lancinating in character, and involving the entire limb. The soft tissue was elevated to the size of a small tumor in the site of the old callus, and had broken down, leaving an ulcerated area. I obtained a section for diagnosis. The report suggested inflammatory tissue. I excised the entire mass, going wide of its border and down to the bone, which was everywhere healthy. During the operation the edge of the knife was turned on some resisting bodies. An examination of the mass showed these to be plates of bone laid down in the fascia, evidently developed at the time of, and along with, the repair of the broken bones. All traces of the neuritis disappeared after this operation, showing that these spiculæ had kept up the irritation through all the years of suffering.

Case IV: Mrs. C., while kneeling on the floor, felt a sharp pain on the outer aspect of the calf of her left leg. Examination showed a drop of blood, and confirmed the suspicion of a needle buried in the soft tissues. I removed a small cambric needle, after prolonged irradiation, with the X-rays, difficulty in seizing it arising from its having penetrated perpendicular to the surface. Eight days later the area exposed became infected, effluvium capillorum gradually developed, and finally necrotic spots

appeared. Repair was only temporary. The scar broke down, forming an ulcer, which did not heal until the entire area was excised. Free excision should be practiced primarily in these cases.

A striking analogy is found in the following case, and throws some light on the way these vibrations damage the tissues of the body.

Case V: E. B., age forty-three years, received an electric shock in his right leg, from the counter electromotive force of a powerful dynamo. The leg from the knee down became red during the following eight days, reaching a maximum. Diffuse ecchymosis and edema appeared in the next three days. Superficial ulcerations developed, involving areas of varying extent. These ulcerations healed in three months, leaving punched-out spots. Pain persisted in the lower limb, aggravated by walking, and amounting to violent causalgia at times. I examined him two years later and found him suffering from causalgia, hyperesthesia of leg from knee down, glossy skin, muscles flabby, and wasting to the extent of an inch and a half. He walked lame on account of the pain and loss of muscular power.

A summary of the effect of the electrical discharge would give: (1) Vascular stasis, (2) vascular paresis, due to vasomotor injury, causing a disturbance of the blood supply to the cells of the part, (3) interference with the trophic influences, (4) direct injury to the cells.

A comparison of these cases shows the same course of symptoms. A knowledge of the character of the different electrical impacts, viz., a succession of lighter ones in Case IV, and a heavy discharge in Case V, all go to support the same cause and lead us rationally to expect the same injury in both cases.-Brooklyn Medical Journal.

SOME PATHOLOGICAL CONDITIONS TO WHICH THE MINER IS PECULIARLY

LIABLE.

BY J. W. COLEMAN, M. D., JEROME, A. t.

The miner's work is peculiarly dangerous. Neither his surroundings nor his manner of doing his work are conducive to health. This paper, however, has nothing to do with the miner's many injuries, caused by falling rock and accidental explosions, but more particularly with the pathological changes found in examining men who for years have followed mining continually. We may for convenience divide these conditions into acute and chronic.

Powder smoke headache is the most frequent acute trouble. Where giant powder is used the patient presents all the symptoms of cerebral congestion. The eyes are watery and bloodshot, pupils contracted. The patient has flashes of light before the eyes, intense headache, restless, twitching muscles, frequent nausea and vomiting, possibly due to stimulation of the vomiting center in the medulla ablongata. The face is pale; the pulse rate and wave are both increased. The first few whiffs of powder smoke may make the face congested, but this soon passes away. Every beat of the heart causes a throbbing pain in the head and humming in the ears. Sometimes the patient staggers like a drunken man, and I have known a mine foreman to discharge one of his men whom he saw stag

gering and reeling on the way to the bunkhouse. Men get accustomed to powder smoke, just as patients get used to taking nitro-glycerine, and the dose must be increased in order to get the desired effect. So in powder smoke, if the miner is in the smoke more than usual he gets the headache, as when he first began mining. Handling giant powder will also cause a headache. It will act as a severe local irritant poison, especially about the eyes, giving rise to severe conjunctivitis and edema. A combination of acetanilide, citrated caffeine, soda bromide and gelsemium will quickly relieve this distressing headache. I prefer the powdered medicine to the tablets, because of its quicker action.

Sudamina is another acute trouble of which I have seen a few cases. All were miners, working in a very hot mine; all were new men. The sweat glands seemed to secrete more sweat than the ducts could carry off. Small blisters formed, with no inflammation and but little itching. The skin was rough, with a pebble-like feeling. The men changed work, no medicines were given, the blebs dried up and scaled off.

The chronic troubles are more serious.

Chronic laryngitis is possibly the most frequent. In my opinion, it is largely caused by the peculiar manner of expelling air from the lungs. With nearly every stroke of the hammer the miner expels the air with a rasping noise, which irritates the vocal membranes. Nearly all miners, while drilling, are mouth breathers. Sometimes the air is cold and dust-laden, which increases the trouble. It will last as long as the cause exists. Medicines are palliative, but not curative.

Chronic bronchitis is another frequent trouble of the miner. His work tends to produce it. Where compressed air is used in drilling the air is extremely cold. His habit of mouth breathing, sudden changes from a warm drift to a cold shaft, the sudden falling or rising of blood pressure caused by the rapid changes in atmospheric pressure, breathing dust and smoke laden air, all tend to produce a chronic catarrhal condition of the bronchi, with morning cough and free expectoration of mucus streaked with pus. This condition is not so dangerous in itself, frequently clearing up nicely by simple rest and outdoor life, aided by a little medicine, yet the man who has an inflamed area in his bronchi is always in danger, because that mucous membrane of lowered vitality is a suitable nidus for tubercle bacilli to lodge and grow. Perhaps this condition can be prevented by teaching the men how to breathe, remembering that God breathed into man's nostrils and not into his mouth.

Miner's consumption is but a step along the same line. I have nothing new to add to this, unless the statement that the lungs take on the color of the material in which the man is working. The lungs of the old coal miner are as black as a lump of coal. The lungs of the hard rock miner are usually gray, especially about the edge, frequently imparting to the touch a gritty, sandy feeling.

I wish to call attention to a peculiar condition of the eyes that I have noticed in old miners and also in blacksmiths; a trembling, twitching, restless, constantly moving condition of the eyeballs, a snappy movement of the eyelids. I have noticed this in hundreds of miners and several blacksmiths. It does not seem to interfere with vision, so far as I know. In the miner I think it is caused

by the flickering candlelight. In the blacksmith it is possibly caused by the forge fire.

Most of the miners work on Sunday. Men have come to me for treatment who have worked over a thousand shifts without missing a day, sometimes doing overtime. These men are simply worn out. Some trifling ailment and the man either quickly dies or is dangerously ill. His vitality exhausted, his surplus energy used up, he has no recuperative power. The Almighty worked six days and rested on the seventh. When he made man he did not endow him with power and endurance greater than a God. The remedy is self-evident.

For some months I have been conducting a series of examinations and urinary tests in order to detect chronic mineral poisoning in miners and smelter men. At present I can only say that I have undoubted evidence of general systemic poisonings by antimony, arsenic, copper and lead. At some future time, when the accumulating evidence is more complete, I will make a report.

In my opinion, it is our duty as physicians not only to endeavor to cure our patients, but to prevent their getting sick. Teach them, then, how to live and how to breathe, and much of the sickness is prevented.-Colorado Med. J. AMPUTATION FOLLOWING RAILROAD ACCIDENT.

DR. EWING MARSHALL.

This young man, on October 16, 1898, in attempting to catch a train going at the rate of eight or ten miles an hour, fell, and the car wheels crushed off his right leg below the knee. The tissues were badly torn away from front to back of the leg. In front there was a fairly clean cut down to the bones, with the bare, jagged ends of the bones protruding an inch or so below. The muscles of the calf were more or less bruised, and extended three or four inches below the ends of the bones.

To give him the benefit of a good stump, with unimpaired knee action, I sawed off the bones even with the short anterior flap and risked an irregular, bruised, and long posterior flap. Much of the bruised tissue sloughed, leaving the bones partially uncovered. I practiced sponge-grafting with fine success, and you see the resultant stump. The boy wore an artificial leg as soon as the stump would stand it until the fall of 1900; then the history is that he became "swoolen" all over, and had such pain in his stump that he was unable to wear his artificial leg the whole of the winter of 1900-1. He began wearing it again, however, early in May, 1901, and wore it constantly and comfortably from that time until about the first of March, 1902. He then again became swoolen all over, the general swelling lasting this time. only four or five days, but though it passed away everywhere else it continued in the stump. He never noticed the purplish color in his stump until the first of March this year. There is at present no pain or tenderness about the stump, and only its size prevents the use of his artificial leg. He has never been a hard drinker, never going further than three or four drinks a day. You will notice the stump is still swollen and has a purplish color.

He had syphilis in 1893 and his condition was such in 1896 that he went to the hot springs at Mount Clemens, Mich., where he was greatly benefited. There has

never been any stomach trouble, and he says his bowels and kidneys are regular. He passed a small quantity of urine at my office yesterday; not enough to get the specific gravity, but it was found loaded with albumen. I would like the members to examine the stump, and will be glad for any suggestions they may have to offer. Dr. F. W. Samuel: This is a most interesting case, and the operation itself has proven that it is unwise in injuries of this class to try and save structures which have been more or less devitalized as a result of the injury. I believe railroad surgeons at present are almost unanimous in their advice to practice high amputation in these cases, getting well above crushed and badly lacerated structures. In this case I believe it would have been better to amputate through the thigh instead of attempting to save the crushed and devitalized tissues below the knee. I am unable to say what bearing the history detailed by Dr. Marshall may have had upon the condition as we now see it. I find, upon examination, that the end of the stump is exceedingly tender; he can not bear the slightest pressure upon it, especially over the end of the tibia. I believe that there is beginning bone destruction and a secondary amputation should be done; also it will give a good stump for an artificial leg. Joints should always be avoided except in extreme cases that are not able to procure an artificial leg.

Dr. J. M. Krim: I agree with what has been said by Dr. Samuel. I do not believe the end of the bone is healthy. It is almost positive from the conditions present that there exists some bone lesion, and secondary amputation above the knee will have to be resorted to in the near future.

Dr. T. P. Satterwhite: The case is interesting from several points of view. I think Dr. Marshall did the correct thing in trying to save as much of the limb as possible. His ingenuity was considerably taxed as a surgeon to provide flaps for covering the ends of the bones under the circumstances. At the time of the accident we can not always tell just how much injury the tissues have sustained in the way of compression, etc. Unquestionably there is now present bone disease; however, I would not advise amputation just at this time; he is comparatively healthy looking; he is a young person, and I would give him the benefit of the hope that it will be possible to avoid the necessity of amputation above the knee. We all know the higher we get in amputation the greater the risk to life, and Dr. Marshall, in my opinion, did perfectly right in amputating where he did. It is impossible sometimes to determine whether or not the tissues have been so devitalized by the injury that repair will not take place. I have no doubt that the bones where Dr. Marshall sawed through them were perfectly sound at the time he amputated, and whether it was the injury that produced the condition as we now see it, or whether it is in some way due to the specific trouble from which the patient has suffered, it is impossible for us to say. At any rate, I would put this boy upon active specific treatment, hoping that this may be the cause of the present trouble, and await further developments before resorting to amputation above the knee.

Dr. G. B. Young: A feature in the case which has not so far been mentioned in the discussion is the probable relation between the renal involvement and the

edema. While it is true the appearance of the stump would indicate a commencing bone lesion, at the same time the fact that he has on two previous occasions had a more or less general edema, which slowly disappeared, would lead us to at least consider whether or not the local edema which is still present may not be the remains of a general edema caused by renal insufficiency, its persistency here being due to the fact that the tissues about the stump are not normal in character. I would be disposed to put this boy upon treatment directed toward removing the edema, improving the action of the kidneys, etc., before I undertook to form a decided opinion as to the basis of the condition present.

Dr. Ewing Marshall: I am obliged to the gentlemen for their consideration of the case and the discussion also. I am strongly impressed with the idea that this boy has a granular kidney, due possibly to some degeneration. That he has had syphilis is certain, and I believe the combination of these two conditions is the underlying cause of the edema which has manifested itself. It is possible, of course, that a secondary amputation will have to be performed later. I did not see the patient in either attack of general edema; I only saw him recently, and as I wanted him to appear before the Society to-night, nothing absolutely has been done in the way of treatment. My idea is to put him on antisyphilitic treatment, with the addition of such remedies as will improve the kidney action.-American Practitioner and News.

FOREIGN BODY IN THE ESOPHAGUS.

At no

by the penny swinging into its vertical position.
time, in the history of the case, was there any complaint
of pain.

On April 10, the X-ray apparatuts at the German Hospital was utilized, with the patient under chloroform, to again locate the penny. Its position had not been altered. Dr. Bender assisted at this procedure. Owing to the small size of the patient's pharynx and esophagus, there was a delay of a few minutes in selecting an appropriate coin catcher. The one found applicable to this case was of slender whalebone, with a s:nall, double swinging basket of silver. This instrument was passed with difficulty, though no force was used. With the fluoroscope, the coin catcher was delicately passed to a point several inches below the penny. During this maneuver, the child was flat on the back, and deeply anesthetized. With the penny and the coin catcher both in sight, the instrument was gradually withdrawn, during which process it could be plainly seen to engage the penny and carry it along the esophagus to the pharynx. As the point was reached, the child's head was lowered, and the coin catcher and its imprisoned penny withdrawn. Length of anesthesia, 15 minutes. The subsequent history of the case is uneventful. The child was kept on fluid food for a few days, and then began her usual diet. No bad after-effects of any kind were noted.

While it is not safe to draw too many conclusions from a single case, the following suggested themselves to the speaker: (1) The desirability of complete anesthesia before attempting to remove foreign bodies from the esophagus. (2) Instruments for introduction. into the esophagus of children should be more flexible than those intended for use in adults. (3) The patient's head should be lowered as the coin is seen to approach the pharynx, in order to avoid its dropping into the larynx. (4) Instrumental exploration with the aid of the fluoroscope should precede any operative attempt. (5) Exploration must be very delicately done to avoid. injury to the esophagus.-Brooklyn Medical Journal.

THE FOOT.

Dr. Russell S. Fowler reported a case of a girl two years old, referred to him by Dr. Arthur C. Jacobson, with the following history: Her father, while playing with her, allowed her to place a penny in her mouth, whence it quickly passed into the esophagus, beyond his recovery. The parents, expecting the coin to pass, delayed taking the child to their family physician until four days later. The coin had not passed, as expected, and the child suffered from inability to swallow solid food, regurgitation being immediate. Liquids passed CONGENITAL OUTWARD DISLOCATION OF more easily. There were slight coughing spells from time to time, but at no time was any blood coughed up. As the symptoms were not urgent, no attempt was made by the family physician to definitely locate the penny, he, at that time, believing it would finally pass downward. The child was seen again on May 8, a week after the accident, by which time she had begun to grow somewhat thin and pale. Liquids were easily swallowed, and solids fairly well. This was probably due to a slight change in the position of the penny. At Dr. Fowler's suggestion, an X-ray picture was taken by Dr. Bender, April 10. Chloroform was administered to keep the small patient quiet. Previous to the taking of this picture swallowing had improved so markedly and suddenly that the parents were disinclined to have anything further done. The fluoroscope examination of April 10 showed the coin vertically placed in the esophagus at the level of the sternal notch. The plane surfaces were antero-posterior, forming a partition on either side of which food could pass. The transition from difficult to easy deglutition was probably caused

Dr. J. B. Bogart presented a case of outward dislocation of the foot, which he said might be classed as an extreme case of talipes valgus. The child is four years of age, and has had the deformity from birth. It gave him no pain and he was able to walk by turning his foot completely outward and walking on the internal malleolus. We very commonly see extreme cases of talipes valgus in which the patients walk with the toe turned out. turned out. There was in this case no particularly outward deviation of the toe, as we see ordinarily in valgus, but simply the complete turning over of the foot when walking. When he came under the speaker's care he was wearing a brace within his shoe, the intention of which was to correct the displacement, but it was evident that the brace did not correct it, and the position was such that it was impossible for it to have any permanent effect. It was possibile to replace the foot in something like a normal position, but there was no means of keeping it there, as the internal ligament of

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