remarkable results have followed the use of this material; its administration seems entirely safe, and it should thoroughly and carefully be tried to ascertain its true rank as a remedy.

XIII. RICKETS.

Rickets is a constitutional disease arising during the early years of life (the first two or three) as a result of insufficient or of improper diet and bad hygienic surroundings. A deficiency of fat and phosphate in the food or the use of a diet which, by inducing gastro-intestinal catarrh, prevents assimilation, causes rickets. The disease is never congenital, the so-called "congenital rickets" being sporadic cretinism (Bowlby). Figure 4 (Pl. 2) shows marasmic rickets.

Evidences of Rickets.-The condition is one of general ill-health; the child is ill-nourished, pallid, flabby; it has attacks of diarrhoea and a tumid belly; it is disinclined for exertion and has a capricious appetite; it is liable to nightsweats and night-terrors; enlarged glands are often noted, the teeth appear behind time, and the fontanelles close late. The long bones become much curved, the upper part of the chest sinks in, curvature of the spine appears, the head is large and the forehead bulges, and the pelvis is distorted. Swelling appears in the articular heads of long bones, beside the epiphyseal cartilages, and in the sternal end of the ribs, forming in the latter case rhachitic beads. The lesions of rickets are due to an imperfect ossification of the animal matter which is prepared for bone-formation, and consequently to softening of the bones which causes them to bend. The swellings at the articular heads are due to pressure forcing out the soft bone into rings. Rhachitic children. rarely grow to a full size, and the disease is responsible for many dwarfs. Most cases recover without deformity, but the time lost during the period when active development

should have gone on cannot be made up, and some slight deficiency is sure to remain.

Treatment. The treatment consists in open air, sunshine, salt-water baths, sea-air, fresh food (milk, cream, and meatjuice), cod-liver oil especially, syrup of the iodide of iron, arsenic, and some form of phosphorus.

XIV. CONTUSIONS AND WOUNDS.

Contusions.-A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured (as in the abdomen) or damaged with a surface-breach (as in a part overlying bone), blood being effused. If a large vessel is damaged, the hemorrhage is large. An ecchymosis is diffuse hemorrhage over a large area; a hematoma is a blood-tumor or a circumscribed hemorrhage. In a diffuse hemorrhage the coagulation of fibrin induces induration; the serum and leucocytes are absorbed; the red blood-cells disintegrate and the coloring matter is widely diffused (suggillation); and hæmoglobin is changed into hæmatoidin, which crystallizes. In union with these chemical changes, color-changes ensue, the part being at first red and then becoming purple, black, green, lemon, and citron. A hæmatoma acts as an irritant, inflammation ensues around it, and it is encapsuled by embryonic tissue, which, by organizing into fibrous tissue, forms a blood-cyst and gradually absorbs the fluid blood, the cystcontents becoming thicker and thicker. A fibrous scar may remain. If serum is not absorbed, hæmatoidin forms and the fluid becomes clear. A hæmatoma may suppurate, an abscess forming.

Symptoms.-The symptoms are heat, tenderness, swelling, and numbness followed by pain. Discoloration appears quickly in superficial contusions, but days after in deep ones; shock and loss of function are present after severe contusions.

Treatment.-Obtain reaction from the shock. Local treatment consists of rest, elevation, and compression to arrest bleeding, antagonize inflammation, and control swelling. Cold is useful early in a case, but it is not suited to severe contusions or to contusions in the debilitated or aged, as in such cases it may cause gangrene. Lead-water and laudanum and iodine may be used. In very severe contusions employ heat and stimulation. When inflammation is subsiding after a contusion, massage and ichthyol should be ordered. A contusion should never be opened unless hemorrhage continues, infection takes place, or a lump remains for some weeks. For persistent bleeding freely lay open the contusion, turn out clots, ligate vessels, irrigate with corrosivesublimate solution, insert a tube, and close. If gangrene is feared, use iodine locally, and if a slough forms, employ antiseptic fomentations. Constitutional treatment for contusion is the same as that for inflammation.

Wounds.-A wound is a breach of surface continuity by a sudden and violent mechanical force. Wounds are divided into open and subcutaneous, septic and aseptic, contused, incised, lacerated, punctured, gunshot, and poisoned.

The local phenomena of wounds are pain, hemorrhage, loss of function, and gaping or retraction of edges.

Pain is due to the injury of nerves, and it varies according to the situation and to the nature of the injury. It is influenced by temperament, excitement, and preoccupation. It may not be felt at all at the time of the injury. At first it is usually acute, becoming later dull and aching. In an aseptic wound the pain is slight, but in an infected wound it is

severe.

Hemorrhage varies with the state of the system, the vascularity of the part, and the variety of injury.

Loss of Function.-Depends on the situation and extent of the injury.

Gaping or Retraction of Edges.-Due to tissue-elasticity. The constitutional condition is that of shock, which is a sudden depression of the vital powers arising from an injury or a profound emotion acting on the nerve-centres and in"ducing vaso-motor paresis, the blood accumulating in the abdominal vessels. It may be slight and transient, it may be severe and prolonged, and it may even produce almost instant death. It is more severe in men than in women, in the nervous and sanguine than in the lymphatic, in those inured to suffering than in those who are strangers to illness. Injury of the abdomen produces great shock, and so does damage to the viscera, the urethra, and the testicles. Cerebral concussion is a form of shock plus other conditions. Sudden and profuse hemorrhage causes shock; so, occasionally, does anæsthetization.

Symptoms.-The symptoms are a temperature much below normal; weak, rapid, and compressible pulse; cold, clammy, or profusely-perspiring skin; shallow respiration; a tendency to urinary suppression; consciousness is usually maintained, but there is an absence of mental originating power, the injured person answering when spoken to, but volunteering no statements and lying with partly-closed lids in any position in which he may have been placed. If delirium arises, the condition is very grave (delirious shock). Pain is slightly or not at all appreciated. Vomiting may, as in concussion, presage reaction. Vomiting after a considerable time in shock is regurgitation, and is a bad omen.

Diagnosis.-Concealed hemorrhage is hard to separate from shock. It produces impairment of vision (retinal anæmia), irregular tossing, frequent yawning, nausea, and sometimes convulsions. In shock the hæmoglobin is unaltered; in hemorrhage it is enormously reduced (Hare and Martin). In hemorrhage recurrent attacks of syncope are met with. Shock and hemorrhage are often associated. The

essential characteristic of shock is sudden onset, which separates it from exhaustion.

Treatment. In treating shock from a wound, lower the head, apply hot bottles and hot blankets, and give hypodermatic injections of ether, brandy, strychnine, digitalis, or atropia. A turpentine enema is useful. Hot coffee or other hot fluids should be given by the mouth and rectum, mustard be placed over the heart, spine, and shins, and the hypodermoclysis of salines be practised. If shock comes on during operation, the proceedings must be hurried or even be stopped. Should we operate during shock? Clearly, no, except for the purpose of arresting hemorrhage. Do not, for instance, perform an amputation in shock, but arrest hemorrhage, asepticize, and bring about reaction before operating. Fat-embolism.-(See Embolism, p. 124.) Fever. (See Fevers.)

Treatment of Wounds.-The rules for treating wounds are (1) arrest hemorrhage; (2) bring about reaction; (3) remove foreign bodies; (4) asepticize; (5) drain, coaptate the edges, and dress; and (6) secure rest to the part and combat inflammation. Constitutionally, allay pain, secure sleep, keep up the nutrition, and treat inflammatory conditions.

Arrest of Hemorrhage.—To arrest hemorrhage the bleeding point must be controlled by digital pressure until ready to be grasped with forceps; it is then caught up and tied with catgut or aseptic silk. Slight hemorrhage stops spontaneously on exposure to air, and moderate hemorrhage ceases after the vessels are clamped for a time; an injured vessel of some size must be ligated, even if it has ceased to bleed. Capillary oozing is checked by hot-water compresses. If a large artery is divided in a limb, apply a tourniquet. before ligating (see Wounds of Vessels).

Bringing About of Reaction.-(See Shock.)

Removal of Foreign Bodies.-Remove all foreign bodies