merely for the purpose of aiding the metabolic changes in the affected region. Today, one month after such simple treatment, the patient declares himself free from all pain, and ready to again resume his vocation, which is not the best thing to do under the circumstances, but he is obliged to earn a living.

Case 4-Mr. B., age sixty-five. Two years ago, developed a "graduallycoming-on-pain" in left hip, walking became more and more difficult. At the end of a year the pain was intense, preventing sleep. The usual remedies were prescribed-massage, liniments, blisters, etc.-but all to no avail. Two months ago, patient was advised by the orthopedic surgeons to go to bed for six weeks with a continuous extension on the limb. Owing to the liability of a hypostatic pneumonia developing in a patient of his age, this advice was not followed. Four weeks ago this patient came under treatment in this clinic. The case was diagnosed as spasm in the muscles of the hip, the result of trauma. There is no agent known that will relieve muscular spasm more surely and more permanently than local light and radiant heat from a high amperage source. The sacral region and hip were exposed for fifteen to twenty minutes to the action of this radiant energy, on alternate days. Today the patient declares himself as perfectly. well, has no ache or pain, and walks without assistance. In cases of this kind, two considerations confront us—the spasm and the consequent inanition of the parts. Both of these conditions are beautifully met by the application of light and heat from a high-power incandescent lamp.

Case 5-Miss R., age seventeen years. One and a half years ago fell and injured the elbow. The patient, apparently, recovered from this for the time being. Six months after the injury the arm began to pain, especially at night. The various clinics were then visited; she was treated for rheumatism with internal medication, without results. The actual cautery was applied over the arm for a supposed existing neuritis, without results. Finally, she appeared at this clinic. (Before any treatment is instituted in this clinic, it is our rule to make a correct diagnosis, and I can not impress upon you too often the necessity for this.) We found here a joint with limited extension, as well as flexion, coming on at least six months after an injury, the elbow joint appearing enlarged, and feeling hotter than the normal one. Upon closer investigation, we found muscular spasm surrounding the elbow joint. An X-ray was taken, and this at once cleared the diagnosis. We are here dealing with a tubercular elbow joint, the lesion being in the lower end of the humerus.

What are, then, the indications for treatment? Just three, and Nature is trying to supply these as best she can, so by following out natural laws we will be led to the correct therapeutic measure; the spasm indicates much-needed rest, which we accomplish by placing the elbow in a light plaster splint; the swelling indicates that additional or extra nutrition is

required; while the heat is a consequence of this extra blood present, and, at the same time, indicates increased metabolic changes. These last two conditions are met by active and passive hyperemia. The splint has been cut, so as to present a lower and upper half. The upper half only is removed, and the light and heat from the lamp cause an active hyperemia in about fifteen to twenty minutes' exposure, to the point of tolerance of the patient. The upper part of the splint is now replaced, and a rubber bandage is snugly applied above the cast, thereby limiting the return flow of the blood, and so causing a passive hyperemia, according to the Bier method. After the second treatment the patient rested comfortably, and has had no pains since then. This treatment must be continued for at least one or two years, and I am safe in saying that if it is persisted in, every tubercular joint is curable.

Case 6-This patient, a woman of fifty-five years, came to this clinic one month ago with a chronic ulcer covering the entire lower leg, from three inches below the knee up to the outer malleolus. She gives a history of having had this for nearly fifteen years, and that she has had more freedom from pain during the last month than for the past year. What, in your opinion, is the underlying condition, over- or under-nutrition? If it is subnormal, then the indicated treatment is simple. We must increase the local nutrition. There is no surer way than by the use of light and heat. All of you can see how the margin is beginning to be covered with healthy granulation tissue. The patient declares herself free from pain, and in the course of another month we will have this ulcer entirely healed over. Keep the lamp in constant motion, about twenty to twenty-five inches from the parts, for about fifteen minutes, to the tolerance of the patient. As simple as the technique, so sure is the result.

Case 7-Another case of chronic leg ulcer. This woman, fifty-nine years old, has been under treatment with the lamp for the past three months. You can all see the margin of the original ulcer, which is now completely healed over. She will continue the treatment once a week for another month, when she will be discharged as cured. Mrs. Mc., how long did you have an open leg before coming here? "Shure, Doctor, its that long ago I could not tell ye." Have you any pain there now? “Not a bit, Lord bless ye, from the first day ye turned that sun on me."

Case 8-Mrs. M., sixty-two years of age. Three years ago began to feel weak, lost her appetite, and for nearly one year was treated for malaria without results. Then the spleen began to enlarge, and her doctor made a blood examination. Splenic leukemia was diagnosed, treated with iron, quinia, strychnine, or tonic treatment (?). Finally, she was treated with the X-ray, but evidently a little too vigorously, for as you see she presents a radio-dermatitis over the entire abdomen. A radio-dermatitis is, perhaps, the most rebellious lesion of all the skin lesions we have.

This patient is subjected to the rays from a high-power lamp, but the light is screened off with the blue-glass screen, allowing none but the blue rays to fall upon the ulcer. The slough has dried, and the edges look healthy. If this patient has nothing else to be thankful for, it is the fact that she is rid of the agonizing pain of a radio-dermatitis. In my experience, there is no one agent that will stop the pain and heal the lesion as quickly as the blue rays from an incandescent lamp..

Case 9-Mrs. R. is the mother of the little patient, one year old. The boy, soon after birth, broke out all over the entire scalp and face with scabs and crusts. This, as the mother tells us, was treated with internal and external medication. The more the baby was treated the worse the disease became. Six weeks ago the patient was brought to this clinic, and a diagnosis of eczema seborrhoica was made. The diet could not be changed, because the baby was nursing, and the mother appeared healthy. A simple ointment of lanoline, with 2% carbolic acid, was ordered for an external application. The baby is exposed to the blue light every other day for fifteen to twenty minutes, or until a gentle perspiration is visible upon the forehead. Under this treatment, the lesion has practically disappeared. The baby has increased in weight, eats and sleeps regularly, and the mother is happy.

In conclusion, I wish to impress upon you again the fact that Nature tends always toward a cure; by making a positive diagnosis, and noting the attempts of Nature in her effort to cure, we are seldom wrong if we simply assist Nature in her effort, rather than blindly trust to luck, and do something which may hinder the natural method of cure.

158 W. 7th street.

FRACTURES OF THE UPPER EXTREMITY OF THE FEMUR.

BY CHAS. BLICKENSDERFER, M. D., Tecumseh, Okla.

[Written for the MEDICAL BRIEF.]

Fractures involving the upper extremity of the femur, on account of the high mortality rate attending them, and the consequent impairment of function, with deformity following; the prolonged and difficult treatment necessary to effect a restoration of function and contour to the injured member, are subjects for special consideration of the surgeon.

Under this term are included fractures of the head, neck and trochanter, with epiphysical separations of the head and trochanter major, and fracture through the great trochanter.

By the term fracture is meant a solution of continuity of bone or cartilage, recently or suddenly made. The causes operating to produce fracture of the femur are the same in general as those serving to produce fractures elsewhere, and are to be divided into predisposing, pathological and active or determining.

The predisposing causes are age, sex, season of the year, occupation and inherited liability.

In that class of fracture under consideration, age is the most potent factor, at least sixty per cent occurring after the sixtieth year. Bones of the aged, and especially the neck of the femur, from a thinning of the cortical layers and an enlargement of the meshes of the spongy portion, with increased deposition of fats, are rendered easy prey to those forces constituting the active or determining causes. This thinning of the bone is known as interstitial atrophy, or osteoporosis, and is thus a natural predisposing cause. But when marked in the middle-aged or extreme in the old, it is generally classed as a pathological condition predisposing to fracture.

Sex is also an important factor, especially in the aged, for in fractures of the neck, the females so far preponderate over the males that this injury has been styled "Old Woman's Fracture." The reason for the greater frequency of this fracture in this sex is to be found in an anatomically smaller and weaker bone in the female subject; and the process of rarefaction that is usually manifest after the fiftieth year is more marked in females than in males.

In fractures of every class, the greater number occur in the open or warmer months of the year. This is owing to the greater physical activity indulged in during the months when outdoor exercises and occupations are at their maximum. In fractures of the neck of the femur, however, the larger number are the result of falls and other accidents during the colder months of the year. This is no doubt due to slipping and falling upon icy and wet surfaces, and to the fact that old people endeavor, after being closely housed during the colder days of the winter, to take exercise on every fair day, their desire for activity at this time exceeding that of the warmer seasons of the year.

Occupation is not a very prominent predisposing cause in fractures of the neck, except when this accident occurs in young adults, when such occupations that involve the manipulation of moving bodies or heavy weights, or the transportation of materials of whatsoever kind, incline to this, but in less degree, than to the remaining classifications.

An inherited liability and a congenital predisposition without inheritance, may be mentioned as unusual predisposing causes to fracture, but a sufficient number of these causes have been tabulated by Gurlt to justify their mention as surgical possibilities.

The pathological causes are caries, necrosis, osteomyelitis, osteoporosis, fragilitas ossium, osteitis deformans, echinococcus, actinomycosis, syphilis, tuberculosis, atrophy from disuse or circulatory defects, fatty degeneration, chronic mercurialism, rheumatism, gout, osteomalacia, tabes dorsalis, general paresis, carcinomatous and sarcomatous degenerations and any

tumor affecting the nutrition of the bone, together with diseases affecting the trophic nerve centers.

About a year ago the writer was called to see an old lady, seventy-two years of age, who suffered from a carcinoma of the left breast. In changing her grandchild from one arm to the other she fractured her right humerus, and a few days later, upon attempting to rise from her rocking chair, she fractured the neck of her right femur.

With the exceptions to be found only in the young adult or the youthful, the exciting or determining causes are usually the exhibitions of slight force operating upon the hip, directly or indirectly, being sufficient, in most instances, to the production of this injury. A misstep, a trip, or a fall upon the trochanter; twisting the body upon the legs, or any forced or sudden movement of the limb upon the trunk. Stepping from a higher to a lower level, or, in short, any force, slight or otherwise, applied vertically upon the sole of the foot, or upon the knee, or laterally upon the trochanter, producing the various forms of fracture in this locality.

The pathology of the several fractures of the femoral neck and vicinity, must, of necessity, be well understood in order to insure a proper interpretation of the symptom complex, establishing a basis for rational treatment. Fractures involving the head alone are very rare, there having been but three cases recorded.

Fractures through the neck usually involve the weakest portion, the constriction just behind the head, and within the capsule. This would constitute the once famous intracapsular fracture of Sir Astley Cooper, but autopsies have shown that fractures of the neck are so seldom wholly within the capsule that the term intracapsular fracture is very seldom altogether applicable, and is, therefore, more of historical interest than of practical utility.

Fractures through the neck may involve any or all portions of the neck, and may lie wholly within or without the capsule, or as is more common, may lie both within and without the capsule, constituting the so-called "mixed fracture.'

Fractures through the constricted portion of the neck are rarely impacted; and partly due to this, and to the fact that in this situation the nutrition of the part is greatly limited, especially if the periosteum be torn, union is seldom obtained. The line of fracture, of course, is not constant, being, for the most part, irregular; and may be transverse or oblique, involving the neck alone, or be accompanied by fractures involving the trochanters and upper extremity of the shaft.

In fractures through the base of the neck the line of fracture is usually along the junction of the neck and shaft, and these are more frequently impacted than any other. The impaction consists, as a rule, in the crushing together of the parts, the fractured surfaces interlocking. The most