Treatment of the shoulder for synovial adhesions: ligamentous or muscular contractions, consists of movements made in the normal direction, but carried farther than the patient can do so voluntarily.

    Diagnosis. -Test the extent of the movements, normal to the articulation, to ascertain whether the loss of movement is general in all directions or results from impairment of some special muscle or ligament.

    Causes of Stiff Joints. - The history of the case will usually give an insight into its cause, progress, etc.  The shoulder articulation is frequently stiffened by a sprain, dislocation, muscular and articular rheumatism.  The simplest cases are those resulting from rest, necessitated by a broken clavicle or humerus.

    The necessary rest after a dislocation gives the strained ligaments an opportunity to shorten and
thicken.  Movements should be frequently forced in such cases to prevent any synovial adhesions.  The differentiation of cases of ankylosis is an important one.  It is disheartening to physician and patient alike to find that after weeks of earnest effort no satisfactory results are obtained.

    An article on "Ankylosis" by J. S. White, D. O., of Pasadena, Cal., published in Vol.  V., No. IV., of The Osteopath, page 211, deserves quotation here because it notes so clearly the important points which the student ought to know.  With his permission, it is quoted in full.

"Ankylosis. - When, from an injury, disease or other cause, a joint loses its function and becomes stiff, it is said to be ankylosed.  This condition may be termed bony (complete) or fibrous (incomplete), true (intra-articular) or false (extra-articular) ankylosis."

    "These are the terms used by Da Costa to define ankylosis, yet some claim that joint-stiffness caused by extra-articular contraction, or obstruction, is not ankylosis in the correct sense; but on looking at the derivation of the word (an(g)kulos - crooked or bent), it seems that the term ankylosis would be correct when applied to any form of restricted joint movement."

    "The causes of ankylosis are many.  First, let us consider those which result in complete and incomplete ankylosis.  Inflammations in or around the joint, from whatever cause, if continued long enough for new tissue formation, will cause ankylosis.  After aseptic inflammations we will most likely find fibrous, but when there is infection, bony ankylosis is more probable."

    "This fibrous formation is the result of inflammation, for wherever there is inflammation there is an increase of tissue.  Suppose a case of dislocation, with considerable contusion of the tissues around the joint, inflammation results, and embryonic tissue begins to form as a reparative process; the embryonic tissue sends out small processes, which start from new centers and spread through the gelatinous mass, in and around the joint, until a very irregular network is spread all around the joint surface, when the contraction process begins, the new tissue is formed into fibrous tissue, which unites the bones closely together; by cicatricial contraction the bones may be drawn so closely together that movement is almost impossible."  "Bony union of the joint surface follows fibrous ankylosis - it occurs when the bone itself is injured or diseased, and ;he surface of the bone eroded or broken.  Ossification begins chiefly in those layers of fibrous tissue lying next to the bone."

    "False or extra-articular ankylosis is caused by the contraction of tissues around the joint.  These contractions, external to the joint, may be the result of many remote and obscure causes."

    "First.  Chronic contraction, which may be due to disease or obstruction to the nerve, at the center, or in its course to the muscles.  As the normal action of muscles is dependent on normal nerve stimulus, a muscle may be affected in various ways by the stimulus of an over-irritated or inhibited nerve; excess of nerve stimulation will cause a pathological contraction, or there may be suspension of nerve stimulus and paralysis of muscles, allowing the opposing muscles to pull and hold the joint in a fixed position."

    "Second.  Contractions sufficient to cause permanent fixations may follow the healing of wounds, ulcers or abscesses.  Active contraction, from any cause, if kept in that state any length of time, can cause the muscle to undergo a state of fibroid degeneration; tissue waste is replaced by fat and fibrous material.  There is good evidence that, after a time, tissues which have not fulfilled their function lose the ability to do so, and the nutritive changes accompanying vital activity do not take place; the contiguous fibers and cells become adherent, agglutinated and united by exuded serum and waste material not carried away by the circulation, sluggish through inactivity of the muscles."

    "The tendons and ligaments around the joint are thickened and hardened to the length the limb was held by the active contraction, but after the manner of all newly formed tissue, it continues to retract and draw the limb more out of its normal position."

    "Third.  Contractions may be the result of certain diseases (as rheumatism, gout, tuberculosis, syphilis, or any disease causing non-use of the joint or malnutrition of the controlling muscles."

    "In examining an ankylosed joint, we must distinguish between bony and fibrous ankylosis and extra-articular contraction.  A joint may be immovable, and yet not so because of bony ankylosis."

    Da Costa says that a joint immovable from fibrous ankylosis is distinguished from a joint immovable from bony ankylosis by the fact that, in the former, attempts at motion are productive of pain and subsequently of inflammation; therefore, pain on attempted motion excludes bony ankylosis from our diagnosis.  An approximate idea of the extent of the stiffness may be obtained from a history of the case as to whether the disease has been severe in character and long in duration.  The nerves of the joint should be examined at their point of exit from the spine and throughout their course to the joint."

    "The same conditions, in general, which cause pain in a joint may cause ankylosis, whether that pain be due to local injury or referred from some other part.  A contracted psoas muscle by irritation to the branches of the obturator nerve can cause pain, contraction and consequent stiffness of the knee joint."

    "What can osteopathy do for this condition?  For bony ankylosis nothing should be attempted, for the treatment would only result in discouragement and disappointment to both physician and patient; but if the joint is in an almost useless position, excision or osteotomy may be tried with good results.  If the joint has become ankylosed through septic inflammation, it should not be forcibly broken up, because of the danger of re-infection of the whole joint, or other parts of the body, through the circulation."

    "In cases of fibrous and extra-articular ankylosis osteopathy can refer to the most encouraging records, and is undoubtedly ahead of any other method of treatment.  The main point in the treatment consists principally in making active the retarded circulation, gradually breaking up the adhesions, thoroughly relaxing all the muscles, and a stimulating treatment to the nerves."

    "For extra-articular ankylosis the treatment is varied according to the cause.  Osteopathy has a great mission to fill in finding and removing the primary cause of many cases of ankylosis.  Hilton speaks of a case of diseased (tubercular) knee joint cured by ankylosis.  True! the rest and ankylosis was nature's way of reducing the inflammation and disease when it had progressed so far.  But the work of the osteopath is to look for the causes which made the knee joint "a point of least resistance" for the tubercle bacilli to multiply in.  Examine the spine thoroughly, the sacroiliac articulation and the hip for dislocations, which cause pain in the knee joint through irritation of the obturator nerve.  But does pain alone in the joints lead to the condition known as a 'point of least resistance?'  Pain prevents much movement in the joint, and remembering that continued non-use of muscles causes malnutrition, sluggish circulation and degeneration of the muscle, we may see how the joint may become a place for germs to multiply."

    "Is it too long a course from simple pain to disease?  Remember that pain is usually accompanied by contraction of muscle.  Our treatment must be both preventive and curative."

    "Following is a case of fibrous ankylosis and paralysis illustrating the efficiency of osteopathy to treat this class of sufferers.  Vincent Pete, five years of age, had an ankylosed elbow as a result of a dislocation and break.  The joint was attended to immediately after the accident by a regular physician, but was kept in the splints too long; which caused the fibrous ankylosis.  The humerus was broken just above the condyles, and a small spicula of bone had protruded so that it interfered with those fibers of the median nerve which supply the flexor muscles of the thumb and forefinger to such a degree that the thumb and forefinger were completely paralyzed, as far as the flexor movements were concerned.  The forearm was ankylosed almost at a right angle with the arm, and a very little movement could be made, and that with great pain; the muscles in the cervical region of the spine were sore and contracted.  This was the condition of the patient when he came for treatment eight weeks after the accident.  The improvement began with the first treatment, and in on month the arm was perfectly straight and movable in any direction, and he began to have power of movement in his finger and thumb; at the end of two months' treatment, his arm had returned to almost its usual strength and flexibility.  I saw him a month later and the arm and hand were perfectly normal.  Contrast this case with one treated by mechanical rest, resulting in a fixed elbow joint, or perhaps a moderately useful joint following forcible breaking of adhesion under anaesthesia, which is a dangerous treatment, with very doubtful results, as the operation may have to be done over and over again before a useful joint is gained."

    The Scapulo-humeral Articulation. - Fig. 233 illustrates a method of prying the head of the humerus out of the glenoid fossa, i. e., separating the articular surfaces.  This movement can be used in cases of muscular rheumatism when complete abduction of the arm is impossible.  It also allows an influx of fresh arterial blood.

    When abducting the arm, the scapula must be held by the physician's hands.  Place the fingers on the vertebral border of the scapula, while the axillary border is compressed by the thumb.  By holding the scapula securely, the physician is sure that all the movement he forces is in the shoulder articulation, and not the gliding of the scapula on the thorax.  The muscles of the arm may be relaxed by direct manipulation.  The insertion of the deltoid is frequently tender.  Any wasting of the muscles of the extremity should be carefully noted, so that the course of its governing nerve may be searched for a point of compression.

    Examination of the Brachial Plexus.  The principal motor divisions of the brachial plexus may be tested by simple movements made by the patient.  The patient's gripping power is an index to the condition of the median nerve, and the muscles it innervates.  Extension of the forearm, wrist and fingers made against resistance is an index of power in the musculo-spiral  nerve tract.  Abduction and adduction of the fingers are controlled by the ulnar nerve.  Flexion of the forearm by the musculo-cutaneous.

    Observe the condition of the first posterior inter-osseous muscle which forms the little muscular swelling when the thumb is adducted to the second metacarpal bone.  If it is wasted there is evidence of nerve cell degeneration.  This muscle should be well developed in thin hands, as well as in fat ones.  If the wasting is unilateral, look for impingement on the ulnar nerve at some point in its course.  If it is bilateral the cells in the spinal cord are probably at fault.

    The deltoid is frequently painful as a result of pressure on the circumflex nerve.  The pressure is usually at the point of exit from the vertebral canal.  Relaxation of the structures around its point of exit usually gives relief.

    Reduction of Dislocations by Traction. - The general method applied to dislocations of all joints of the extremities is direct traction.  This is sometimes aided by pressure on the prominent point of the dislocated bone to aid it in slipping to its place.  All of the dislocations of the humerus, subcoracoid, subclavicular, subglenoid and subspinous, can be reduced by using traction to stretch the muscles and ligaments of the joint to the extent that the head of the humerus will slip over the rim of the glenoid fossa.  This traction may be made with the patient sitting, as in Fig. 234.  The knee in the axilla springs the head of the humerus outward.  The same treatment may be applied with the patient reclining.  The physician should place a ball of woolen yarn in the axilia, then place his stockinged foot upon it, and make traction on the arm.

    It is possible to apply the traction method in a simpler way.  An ordinary canvas cot, with a hole cut in it, so that the arm can be put through while the patient rests easily on his side, should be elevated far enough from the floor to allow a six-pound weight to be attached to the wrist.  This steady weight quickly relaxes the muscles and reduces the subluxation.

    Traction always strains the muscles and causes some heat and swelling, therefore, care should be taken to prevent exudates and adhesions.

    Reduction of Dislocations by Leverage. - Those who are expert in reducing shoulder dislocations, usually make use of a series of movements which exaggerate the lesion, i. e., make the head of the dislocated bone more prominent.  In subcoracoid dislocations of the humerus, abduction of the arm causes exaggeration.  The physician stands at the side of the patient, who is reclining on a hard surface.  As abduction is made, the physician's free hand rests upon the head of the humerus.  From the position of abduction the arm is carried inward and forward on a level with the shoulder, at the same time being rotated internally so that the external condyle will be in front of the patient's nose; then carry the arm downward to the side with a quick, vigorous movement, at the same time exerting pressure on the head of the bone as before mentioned.  This series of movements must be made quickly, and the pressure on the head of the bone be most intense while the internal rotation and adduction are at the maximum.

    This series of movements may be employed to break up synovial adhesions.

    Elbow Dislocations. - Elbow dislocations are infrequent compared to those of ball and socket joints.  The possible dislocations of the ulna are lateral and posterior.  The former require traction, the latter is reduced by placing the bend of the patient's elbow over the physician's knee.  Traction with one hand on the patient's wrist, while the other hand makes pressure on the olecranon, will force the ulna into place.  This dislocation is usually complicated with fracture of the coronoid process.

    The Radius. - The radius may be dislocated posteriorly or anteriorly.  Lateral dislocations of either radius or ulna carry both bones together.  A posterior dislocation of the radius can be reduced by flexion of the forearm, then extension with counter pressure on the prominent point of the head of the radius posteriorly.  A forward dislocation requires supination of the arm and adduction of the hand, together with pressure on the anterior surface of the head of the radius.

    Dislocations of the bones of the wrist or hand are reduced by traction or pressure.

    Old Dislocations. - All dislocations, twenty-four hours old, require considerable relaxing treatment.  The older they are, the harder they are to reduce.  Nature begins to adapt herself to new conditions almost immediately.  All the slack of muscles and ligaments is swiftly taken up.  Those tissues most compressed by the new position of the bone are impoverished by the lack of nourishment.  Thickenings and adhesions quickly form, so that old dislocations are not easily handled.  Old dislocations are treated in the same manner as fresh ones, except that much relaxing and restoring of vitality is necessary.

    Muscles of the Lower Extremity. - The muscles of the lower extremity may be relaxed, either by direct manipulation or by taking advantage of the movement of various joints to put them on a stretch.  Direct manipulation is laborious and requires considerable time.

    The muscles of the hip joint frequently contract sufficiently to make walking difficult.  They contract as a result of strain, bruise, disease of the joint, subluxation of lumbar vertebrae, or luxation of the iliac bones.  The subluxations irritate the nerves which innervate the muscles controlling the joint.

    The movements hereafter outlined may be used for many different purposes, but they are applied here to specific groups of muscles.  All the movements we have thus far outlined have been described according to the way they affect structure, not function.

    Quadriceps Extensor. - The quadriceps extensor of the thigh is innervated by the anterior crural nerve.  In order to stretch this muscle the patient should lie face downward.  The physician grasps the patient's ankle with the left hand, as in Fig. 235.  The right hand holds the pelvis to the table.  Lifting with the left hand puts the muscle on a tension which can be easily increased by flexing the knee.  This movement stretches the fascia over Poupart's ligament and the saphenous opening.

    Fig. 236 illustrates a movement similar to the preceding, but it is not so powerful.  When the patient lies on the side, his back bends to the force of the movement of the leg.  If the physician grips the ankle instead of the knee there is a great increase in the effect of the movement.

    The Adductor Group. - The adductor group of thigh muscles, innervated by the obturator nerve, can be stretched as in Fig. 237.  If there is any inflammation in the acetabulum, this movement will cause the patient great distress, because it stretches the teres ligament.

    Dislocation of the Femur. - Dislocations of the hip joint are usually caused by the forcible spreading of the legs.  The head of the femur is thus forced over the edge of the acetabulum at its dependent and weakest part, the cotyloid notch.  It passes into the thyroid foramen, and if it remains there all the muscles are stretched very tightly, and no voluntary movement is possible.  The direction the head takes is dependent on the direction of the force.  If the knee points anteriorly at the time of the forced extreme abduction, the head, after entering the thyroid foramen, passes out of it posteriorly and takes a position over the spine of the ischium, great sciatic foramen or outer surface of the ilium, all owing to the vigorous pulling of the muscles.  If the knee points posteriorly, the head of the femur travels to a position under the anterior inferior spine of the ilium.

    The movements made to reduce these subluxations take into consideration the fact that the head of the femur must be made to retrace its route in order to regain its proper position.  For example, a dislocation posteriorly onto the spine of the ischium causes the toe to turn inward, and there is slight shortening of the leg.  The physician takes a position as in Fig. 239 and carries the knee upward and inward.  He forces the knee as far as possible across the median line, then flexes the thigh hard on the abdomen.  This turns the head of the femur downward and inward.  Remember that the head points always in the same direction as the internal condyle.  Now, forcibly abduct and extend the thigh with a quick external rotation.  These movements cannot be made successfully without a long course of preliminary relaxing treatments, that is, if the dislocation is an old one.

    Direct traction may be used for all dislocations of the femur, just as for the shoulder, but the muscles are so strong that it is no small matter to overcome them, hence movements which take advantage of leverage are much more satisfactory.

    The formula for any dislocation of the hip may be worked out by noting the position of the head of the femur and then carrying the internal condyle so as to make the head retrace its course.  When shortening or lengthening of the leg is noted, make sure that the iliac bones are even.  A half-inch difference in the length of the legs may easily be accounted for by the action of the hip muscles.

    The pyriformis muscle may contract and compress the sciatic nerve in its course through the great sciatic foramen.  Fig. 239 illustrates the movement to stretch the pyriformis.  The physician holds the pelvis to the table by pressing on the anterior superior spine of the ilium.  The thigh is then strongly adducted.

    Stretching the Sciatic Nerves. - Sciatica is frequently successfully treated by relaxing the pyriforinis, but the majority of cases require a stretching of the sciatic nerve, which is performed as in Fig. 238.  The physician has great leverage in this movement.  It stretches all the flexor group on the back of the thigh.

    The Calf Muscles. - The calf muscles sometimes contract and make it difficult for the patient to get the heel to the floor.  Fig. 240 illustrates the method of applying leverage to the case.

    Scientific Manipulation. - Every group of muscles in the body can be relaxed by stretching them, hence if the student will study their attachments and the effects of their normal contraction, a series of movements can be devised to suit the condition.  Learn anatomy in a practical manner and a system of osteopathic movements will spring forth from the understanding mind of the student.  The author has tried the plan of not demonstrating movements to students, but putting the whole attention to understanding the conditions in the patient which require treatment.  A study of the mechanical difficulties presented and the comparison of these with the normal relations, leads the student to apply anatomical knowledge in treatment.  If the student understands the case, that is, realizes the significance of the points found by the physical diagnosis, he can be depended upon to apply a rational method of treatment.  As soon as the student makes a movement in a certain manner in order to copy his instructor, instead of basing it on his own understanding of the condition treated, he degenerates to mere empirical methods.

    Saphenous Opening. - The circulation in the lower extremity is frequently affected on the venous side by tension at the saphenous opening.  Enlargement of the superficial veins of the leg, above a point three or four inches above the ankle, denotes obstruction to free blood flow in the long saphenous vein.  Abduction and tension of the thigh will stretch the fascia forming the saphenotis opening, then place the thigh in a semi-flexed position, as in Fig. 241, to facilitate direct manipulation of the tissues forming this opening. The deep and superficial veins of the leg have little or no communication above a point about the junction of the lower and middle third of the leg.  This applies especially to the long saphenous vein.  Varicose veins on the feet or ankles may be drained by both superficial and deep veins, therefore, their existence in these locations may be due to visceral causes, even when there is no obstruction to the saphenous opening.

    Popliteal Space. - The popliteal space sometimes needs relaxation.  This is performed by direct manipulation, as illustrated in Fig. 242.  The position of the physician's hands in this illustration affect the upper portion of the popliteal space.  By facing the patient the lower portion can be easily affected.

    The Semilunar Cartilages of the Knee. - These cartilages, which serve to form cup-like depressions for the condyles of the femur to rest in, on the superior articular surface of the tibia, may become slightly displaced and hence act as wedges to limit motion in the joint.  Since they normally move with the condyles, it is probable that some slight ligamentous strain is primarily the cause of the change in position of a semilunar cartilage.  The external semilune is the one most frequently affected.  The reason for this probably is due to the fact that the internal condyle of the femur is longer than the external, hence in a movement, such as pedaling a bicycle, the extension of the joint is made with the knees rather wide apart.  This tends to strain the external lateral ligament.  The cartilage slips slightly forward and prevents either flexion or extension.  The joint remains in a semi-flexed position and is exquisitely painful.  Some of these cases can be quickly relieved by having the patient sit, so that the operator can grasp the knee with both hands, as in Fig. 243.  The operator's thumb makes careful pressure on the painful spot where the external semilune causes a little transverse ridge.  By gently rotating the tibia and using a slight effort to slide the tibia on the condyles, without producing either flexion or extension, the semilune will tend to yield to the thumb pressure and resume its normal relations to the condyle.  Since some swelling accompanies such an accident, it should not be expected that complete flexion, or extension, would be possible immediately after replacement of the semilune.  Any trauma of a ligament is accompanied by the swelling incident to normal repair.

    Paralysis of External Popliteal Nerve. - One of the most frequent forms of peripheral paralysis involves the Peroneal or External Popliteal nerve.  Its position, with relation to the fibula, subjects it to possible pressure, when one knee is crossed over the other.  It is also subject to injury when traction is made on the leg, for a considerable time, as is frequently done in cases of hip joint injury or fracture of the femur.  Surgeons realize the danger of making traction below the knee joint, but there are still enough of these peripheral paralyses, due to this cause, to make it evident that not all physicians realize the danger.  This form of peripheral paralysis is characterized by ankle drop.  In cases of Peroneal paralysis due to pressure, recovery is nearly complete in a few weeks.  This seems to show  that a slight edema exists in the sheath of the nerve at the point which suffered the traumatic pressure. In those  cases due to extension of the leg, recovery is always problematical, because the traumatic pressure may have been produced by a fold of fascia.  This is especially the case when the anterior tibial nerve is the only branch of the Peroneal, paralyzed.  These cases need to be treated by semi-flexing the knee, so that deep digital manipulation, of all the soft tissues of the knee, will hasten absorption of the edema. judging by some of the cases we have seen the patients would have been in more capable condition with bony deformities, due to fractures, than with the paralyses, resulting from the efforts to maintain reduction of the fractures.  These paralyses are, however, unavoidable in some cases, but recovery would be more rapid and certain if intelligent manipulation was used almost from the beginning of the cases.

    "Glucokinesis and Mobilisation." - Many efforts have been made to develop a method of treating fractures, that will not only insure a reasonably perfect union but will avoid the serious sequelae incident to the use of casts, splints and extension apparatus.  No single method of treatment is applicable to all forms of fractures, but there are certain principles, underlying the art of manipulation, which are applicable in the treatment of certain forms of fractures.  The use of a form of massage, by Dr. just Lucas-Championniere, in the treatment of fractures, is a new development in the art of manipulation.  He calls his method "glucokinesis," painless massage.  It is so different from massage, as generally understood by masseurs, that none but physicians, who understand the phenomena in tissues involved in fracture, can use it intelligently.  It consists in stroking the injured part very gently, in the direction of venous circulation and the muscle fibers.  This stroking is rhythmical and continuous for about fifteen or twenty minutes.  The stroking is so gentle as to seem quite ineffective.  The first principle is: "Never be afraid of rubbing too gently, or of giving too small a dose of mobilisation; always fear that the massage is too heavy and the movement too great." The result of this stroking is the relief of pain in the injured part and a coincident relaxation of the muscles involved in the fracture.  This relaxation of muscles allows replacement of the fragments.  Mobilisation consists of minute "doses" of passive movement in all of the joints above and below a fracture.  The "dose" should cause no pain in the limb.  The application of Prof.  Lucas-Championniere's methods has been excellently described by Dr. James B. Mennell in his work on The Treatment of Fractures by Mobilisation and Massage, MacMillan and Co.

    Pain in the Legs and Feet. - Many cases complain of pain of variable character in the legs and feet.  It is good practice to test the plantar arches in all such cases.  Weakness of the longitudinal arch may not be evident except when the leg muscles are fatigued, therefore a plantar impression may not show any sagging.  If no structural defect is apparent, it is safe to assume that weakness exists.  The application of strips of adhesive, to parallel the suspected tendons, will give enough support to demonstrate whether the diagnosis is reasonably correct.

    Tarsal ligaments may be strained, or a tarsal bone become subluxated.  The pain, incident to these conditions, is very acute.  Subluxations are usually reduced by passive movements, which merely tend to produce mobility in the tarsus as a whole.  If this does not produce reduction, it will be necessary to use thumb pressure over the prominent painful spot and then flex and extend the tarsus with the other hand, so as to allow the pressure to become effective.  In any case of weak arch, or subluxated tarsal bone, it is advisable to use some means of passive support until the acute phases are past.  Some cases will recover completely under the influence of voluntary exercises, while others cannot get along without support.

    Varicose Veins. - The pain incident to varicose veins may be very severe.  The first thing to determine is whether the varicosity is due to local or general conditions, i. e., whether there is involvement of one group of veins in a single extremity, or a general back pressure in all the veins of the body, due to a lesion in the right auriculo-ventricular valves, or muscular insufficiency.  The varicosity due to pregnancy is in a class of its own.  The veins on the shin lie so close to the surface that a very slight abrasion causes a varicose ulcer.  The weight of the column of blood, in the long saphenous vein, serves to break down the granulations by which healing tends to take place.  In such cases, whether due to local or systemic conditions, it is best to furnish the vein an artificial support by strapping with strips of adhesive plaster directly over the ulcer and for a space of three inches on all sides of it.  These strips should be about one inch wide and lapped on to each other about one-quarter inch, as in Fig. 250.  This artificial support should be left in place three days, then be stripped off, the ulcer cleansed and fresh adhesive applied.  The amount of exudate will decrease rapidly under this treatment.  Previous to the first dressing, there should be no application of irritating antiseptics.  The mechanical principle of supporting the wall of the vein is all that is necessary.  The moisture of the ulcer will keep the adhesive from breaking the granulations as it is pulled off.  As soon as the discharge from the ulcer ceases there is no necessity for removing the adhesive for many days.  In the meantime such general help, as may be possible, should be given to overcome the conditions which predispose to a recurrence of the ulcer.