EPIPHYSITIS OF THE OS CALCIS.

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EPIPHYSITIS OF OS CALCIS.-MUNICIPAL DISPENSARIES & TUBERCULIN.

.serious degree of rustiness has been caused, even when the water has not been so over-dosed with alum as to render it acid. He concludes that a very soft public supply should, as a rule, be hardened by the addition of small quantities of lime, say 10 to 15 parts per 1,000,000-a practice which, partly on ’account of the risks of lead poisoning, has long been followed in the case of several public water-supplies of moorland origin in this country. Given a supply capable of causing rustiness, the degree of the nuisance largely depends on the temperature at which the water in the circulating hot-water system is maintained and the rate at which it is used. Rapid circulation and a temperature near to boiling point favour the formation of iron rust, and this is also more marked in hot-water systems The important part played which are under high pressure. by electrolytic action is generally recognised, and marked differences have been noted between different qualities of iron and steel pipes in their ability to resist corrosion. It is generally considered that "high quality"and uniformity in the composition of the metal of pipes and boilers should be insisted upon, but there seems to be considerable uncertainty as to the nature of the specification to be made and the tests to be used to see that the specification is complied with. There is no doubt that in the case of some public supplies hot-water installations which are free from all iron or steel will in the long run prove the most economical. We should add perhaps that the " red water " trouble to which we allude is to be distinguished from the occasional rustiness that is often observed merely in the first flow of water drawn from a hot-water tap or a gas heater. This may be observed on any water-supply, and is apparently due to local electrolytic action at the junctions of different metals at places where the temperature of the water is high. -

EPIPHYSITIS OF THE OS CALCIS. IN the New York 3fedieal Journal of May 18th Dr. James Warren Sever, of Boston, has called attention to a painful condition of the heel in children which he has found not uncommon--epiphysitis of the os calcis. It generally occurs in children who are over weight for their years, are physically active, and have strong muscles. The child is I generally seen on account of a slight persistent limp, with ’, disinclination to complete the full step in walking. Tenderness, which has persisted for several weeks or months without change, is complained of about the posterior aspect of the heel low down. The child has usually worn a low shoe There may or may not be a history of injury. or sandal. The foot may be slightly pronated. On examination an area tender on pressure is found over the posterior portion of the os calcis, deeply situated in front of the tendo Achillis on either side. There is moderate thickening about the whole of the posterior portion of the os calcis, with diminution of the hollows on either side of the tendo Achillis. The movements of the foot are slightly limited, especially in full dorsal flexion, and any movement which tends to put a strain on the tendo Achillis is painful. There are pain and tenderness on weight-bearing when the heel is put on the floor, but less when walking on the toes with the heels elevated. The condition resembles somewhat inflammation of the bursa between the tendo Achillis and the os calcis, but is more extensive and more deeply situated. Another condition to be excluded is tenosynovitis of the tendo Achillis. This is distinguished by the presence of tendon crepitus and the pain referred to the tendon itself. Irritation of the bursa between the tendo Achillis and the skin of the heel from shoe pressure has also to be differentiated. Skiagraphy will usually settle the question at once, but even without this the diagnosis is fairly obvious. Whenever ossification of the epiphysis of

calcis is sufficiently developed there will be seen o’l comparing plates of the two feet an enlargement of the

the

os

affected epiphysis both in length and thickness. There is also considerable cloudiness along the epiphyseal line. suggesting a deposit of new bone, and often partial obliteration of this line. A similar condition has been described in the tubercle of the tibia and termed Schlatter’s disease. The treatment is usually simple. There are two indications -to relieve the strain on the tendo Achillis (which is attache(l to part of the epiphysis) and to prevent undue weight-bearing For the former purpose the heel of the shoe is on the heel. raised one-quarter to half an inch. Strapping with vertical strips of narrow adhesive plaster, extending around the heel and well up the leg on either side, gives great relief and support. If there is much pronation an eighth of an incli pad is put on the inner edge of the heel to tip the foot out slightly. To prevent pounding of the heel in walking a rubber heel is used, and a pad of sponge rubber is put inside the heel of the shoe. Other procedures of use are hot and cold douches, electric heat baths, and rest. The duration of the condition varies greatly. Complete cure may be achieved in a few weeks, but more often the disease lasts several months, and may recur after over-use or injury at any time before puberty. Ultimately permanent cure is attained on fusion of the epiphysis with the os calcis.

MUNICIPAL

DISPENSARIES AND TUBERCULIN. "

IN view of the administration of "sanatorium benefits," which is now a matter of immediate concern, the paper which we publish in another column in abbreviated form, and which was communicated by Dr. Mearns Fraser and Dr. Hilda Clark to the Congress of the Sanitary Institute at York this week, is of considerable interest. It deals with the curative measures for tuberculosis inaugurated by the Portsmouth town council. The general organisation seems to have been laid down on careful and sound lines, and stress is laid on the importance of establishing every scheme of this nature on a broad basis, an excellent A dissentiment to promulgate before a lay audience. pensary for administering tuberculin treatment, which is the definition of the Portsmouth Dispensary, is certainly not the only weapon necessary in attacking successfully the tuberculosis problem. If that portion of the National Insurance scheme which is intended to benefit tuberculous patients is to succeed, in addition to dispensaries, hospitals, sanatoriums, home supervision, and suitable provision for children, among other things, must be provided. Further, in any municipal or other scheme for combating tuberculosis the cooperation of the general. practitioner is essential ; without such aid the dispensaries and allied measures will lose much of their, value. Dr. Fraser and Dr. Clark give details of the treatment by tuberculin, and the tone they adopt is a moderate one. We would here urge, however, that reliance on the value of tuberculin as a therapeutic agent must not be too profound. Undoubtedly, in certain cases it is of great value, but when, as is shown in Table VI. of the article, 100 per cent. of "arrested"cases is claimed, those who have had extended experience in pulmonary tuberculosis may well pause and question the means of diagnosis which have been adopted. Such a result is only obtained in those cases in which the signs and symptoms are indefinite but there is a positive reaction to tuberculin. Numerous competent observers have shown that tuberculin as a diagnostic reagent may be fallacious, and therefore the apparent success obtained cannot be taken as the true indication of the. therapeutical powers of the remedy. Probably other