tissue inflame and suppurate. The entire length and thickness of the shaft may be involved, and the periosteum becomes infiltrated, detached, and retracted from the edges of the bone-wound. The soft tissues around the bone also inflame and sometimes slough. More or less necrosis is inevitable.

The symptoms of acute diffuse osteomyelitis from wound are—a very severe boring, gnawing, aching pain; great tenderness; deep swelling of the soft parts over the bone; the skin is healthy early in the case; a profuse offensive purulent discharge containing bone-fragments and tissue-sloughs is poured out; the periosteum is red, thick, and separated; a fungating foul mass protrudes from the medullary canal; rigors, sweats, and fever point to septicemia or pyemia.

Treatment. In treating acute diffuse osteomyelitis expose the interior of the bone, curet the medullary cavity, swab it out with pure carbolic acid, and pack it with iodoform gauze; drain; apply antiseptic dressings; frequently cleanse; and use strong supporting treatment. When the sequestrum loosens, it should be removed. Some cases require amputation.

Acute Epiphysitis.-Acute osteomyelitis without a wound is called "acute infantile arthritis" or "acute epiphysitis." It affects the young, especially children of from one to two years of age, but occasionally arises in older persons (ten to fourteen years). It begins at the epiphyseal line. A strain may occur at this point, inflammation follows, and a hospitable welcome is extended to micro-organisms which are contained in the body-fluids and which pass through this area. In some cases chilling of the body is the predisposing cause. In some patients no history of injury is obtainable; a preceding illness, especially a specific fever, being responsible for the weakening of tissue-resistance. New tissues are always more susceptible to infection than old tissues, and one of the most susceptible of new tissues is the young bone at the end of the diaphysis. Septic organisms may lodge in this area, multiply there and produce systemic poisons. The femur and tibia are the bones most often attacked, the hip-joint or knee-joint being secondarily involved; the humerus, tibia, radius, ulna, and other bones may be attacked; the shoulder-, ankle-, or elbow-joint may become secondarily affected. The youngest bone around the ossific centre first inflames, necrosis takes place, a small sequestrum forms, and the pus around the sequestrum is apt to make a cloaca and empty into the adjacent joint, lighting up a suppurative inflammation of the articulation, and into the medullary canal, causing diffuse osteomyelitis.

The symptoms of acute epiphysitis usually come on suddenly and especially at night, and the attack may be so acute as to cause death by systemic poisoning before a diagnosis is arrived at. The disease is generally ushered in by a chill, which is followed by septic febrile temperature. The history will sometimes contain the statement that the patient was suddenly chilled after being overheated (sitting in a draft or in a cellar on a hot day, possibly swimming when very warm, etc.). There is violent, burning, aching pain in the bone and great tenderness near the joint; the soft parts, which at first are healthy in appearance, after a time discolor, swell, and present distended veins; the neighboring joint swells, and may become filled with pus; the periosteum and the shaft are involved for a considerable distance; each epiphysis may become affected, the shaft between being comparatively uninvolved, and the epiphyses may separate, displacement and shortening taking place. This disease is often mistaken for rheumatism because of the jointswelling, occasionally for typhoid fever because of the fever, and in some cases for erysipelas because of the redness of the skin. It gives a very grave prognosis. Sometimes an epiphysitis shows milder symptoms and is slower in progress (subacute). These cases are very often mistaken for rheumatism. But in rheumatism the joint is the part involved from the beginning, while in epiphysitis the joint is involved secondarily after obvious evidence of inflammation well clear of the articulation. Further, the symptoms of rheumatism can be rapidly improved by the use of the alkalies or the salicylates.

Treatment. In treating acute epiphysitis do not wait for fluctuation, but incise at once; break through the bone at one or more points with a gouge or chisel; curet; chisel away the diseased bone, and if necessary curet the medullary canal; irrigate with corrosive-sublimate solution; swab out with pure carbolic acid; use iodoform plentifully; pack; drain the joint if it is involved; employ rest, anodynes, and strong supporting treatment. Remove dead bone subsequently when it becomes loose. Amputation may be required.

Chronic osteomyelitis is usually linked with osteitis. It may eventuate in osteosclerosis with filling up of the medullary canal, or in limited suppuration, or in caseation of the cancellous tissue (Brodie's abscess), or in necrosis. A tubercular inflammation is one form of chronic osteomyelitis. Syphilis, typhoid fever, etc., may cause it.

Osteomalacia, or Mollities Ossium.-In this disease the bones are partly decalcified, and consequently soften and bend. Many bones are usually involved. It is commoner beyond than before middle age, though it may occur in infancy; it is commoner in women than in men, and pregnancy seems to bear more than a casual relation to its production. In osteomalacia the medulla increases in bulk and becomes more fatty, and the osseous matter is absorbed gradually, first from cancellous tissue and then from the compact tissue. Some observers believe this curious condition is due to lactic acid in the blood.

Symptoms. The symptoms of osteomalacia are as follows: many points of pain which are often thought to be due to rheumatism; deformities from twisting and bending of bone; and a large excess of calcium salts in the urine. This disease lasts a number of years, but usually causes death from exhaustion, though some few cases are arrested or cured. Fractures occur from very slight force.

Treatment. In treating osteomalacia in women insist that pregnancy must not occur. Put braces and supports upon distorted limbs to prevent fracture. Advise good air, hygienic surroundings, and nourishing food. Among the medicines that can be used may be mentioned cod-liver oil, lime salts, preparations of phosphorus, and bone-marrow. In women the removal of the ovaries sometimes cures. It has been asserted that the production of anesthesia by means of chloroform is of great benefit.

Acromegaly.-This is a disease which causes progressive and often great enlargement of both the bones and soft parts of the extremities, which enlargement is symmetrical. The lower jaw projects in advance of the upper jaw, the nose becomes prominent and thick, the supra-orbital ridges are accentuated, and the costal cartilages and inner ends of the clavicles become protuberant. Later the larynx, ribs, shoulder-blades, and vertebræ become involved, and the back becomes markedly humped (cervicodorsal hump). The hands and feet are affected in advanced cases. As a rule, the thyroid gland is enlarged, and a postmortem examination may detect an enlarged pituitary gland. Severe and uncontrollable headache is sometimes a distressing feature of the disease. Treatment is futile. The disease slowly but surely causes death.

Leontiasis Ossium (Virchow's Disease).-This is a hypertrophy limited to the facial and cranial bones, which is symmetrical, and which begins, as a rule, in the superior

maxillæ. The hypertrophy progressively increases, causes difficulty of mastication, and is accompanied by headache. It produces distinct deformity of the jaw like a tumor, whereas acromegaly enlarges all of the proportions of a bone. Treatment is not satisfactory, as a rule. Recently Horsley has obtained amelioration by operating and removing masses of bone.

2. FRACTURES.

Definition. A fracture is a solution, by sudden force, of the continuity of a bone or of a cartilage. Clinically, under this head are placed epiphyseal separations and the tearing apart of ribs and their cartilages.

Varieties of Fractures.-The varieties of fractures are as follows:

Simple fracture is a subcutaneous fracture, or one in which no open wound admits air to the seat of bone-injury. This corresponds to a contusion of the soft parts.

Compound fracture is an open fracture, or one in which an open wound admits air to the seat of bone-injury. This corresponds to a contused or lacerated wound of the soft parts.

A primary compound fracture is one in which the breach in the soft parts is occasioned at the time of the accident, either by the direct violence of the injury or by the forcing of a bone or bones through the tissues.

A secondary compound fracture is one in which the breach in the soft parts occurs after the accident, either from sloughing of damaged tissues, from ulceration because of the pressure of ill-adjusted fragments, or from the forcing of a bone or bones through the soft parts because of rough handling, neglect, or the tossing of delirium.

Complicated fracture is a fracture plus the complication of a joint-injury, arterial or venous damage, or injury to the nerves or soft parts. When a fractured rib injures the lung or when a broken vertebra damages the cord we have a complicated fracture. The term is a bad one, as it conveys no definite meaning, and is no more justifiable than it would be to speak of "complicated pneumonia" or "complicated typhoid," for we should always give a name to the complication in any case. It should be remembered that damage to the soft parts not sufficient to admit air to the seat of fracture does not make the case a compound fracture, but rather complicates a simple fracture. Remember also

that even superficial areas of tissue-destruction must be treated antiseptically, otherwise absorption of pus-elements and their deposition at the seat of injury may cause diffuse osteomyelitis.

Complete fracture is that which extends through the whole thickness of a bone or entirely across it.

Incomplete fracture is that which extends only partially through the thickness of a bone or only partially across it. A linear, hair, capillary, or fissured fracture, or a fissure, is a crack in a bone with very little separation of the edges. This is an incomplete fracture, but may be associated with a complete break.

A green-stick, hickory-stick, willow, or bent fracture is a true incomplete break. It is commonest in the forearm or clavicle, it arises from indirect force, and it is very rare after the age of sixteen. It is called "green-stick" because the bone breaks like a green stick when forced across the knee, first bending and then breaking on its convex surface. The bone, being compressed between two forces, bends, and the fibers on the outer side of the curve are pulled apart, while those on its concavity are not broken, but are compressed. In correcting the deformity the fracture is apt to be made complete. The permanent bending of a bone without a break may possibly occur in youth.

Depression-fracture occurs when a portion of the thickness of a bone is driven in by crushing. Fracture by depression is a result of the bending in of a bone (as the parietal), a fragment breaking off from the side toward which the bone. is bending. A depressed fracture is complete, not incomplete, and by this term is meant an injury in which a fragment of the entire thickness of the bone is driven below the level of the surrounding surface.

Splinter- and Strain-fracture.-The breaking off of a splinter of bone (splinter-fracture) or of an apophysis constitutes an incomplete fracture. A strain upon a ligament or a tendon may tear off a shell of bone, and this injury is the "strain-fracture" of Callender.

Longitudinal fracture is a fracture whose line is for a considerable distance parallel, or nearly so, with the long axis of the bone. This is common in gunshot-injuries.

Oblique fracture is a fracture whose line is positively oblique to the long axis of the bone. Most fractures from indirect force are oblique.

Transverse fracture is a fracture whose line is nearly transverse to the long axis of the bone (no fracture is mathemati