Principles of Osteopathy
Dain L. Tasker, D. O.
CHAPTER XXIII - Extremities
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
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
"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
"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
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
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
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
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
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.