dressing with iodoform; by excision, followed in some instances by sliding in of a flap of sound tissue or immediate skin-grafting. If we are treating a nodular and non-ulcerated area, wash it with a 2 per cent. solution of corrosive sublimate and inject several nodules with camphorated naphtol, one drop for each nodule. In seven or eight days inject other nodules, and so on. Koch's lymph has cured some cases of lupus. Tubercular glands before breaking down should be rubbed with ichthyol, and if this fails to cure they should be removed. When they break down they should be removed or opened, curetted, and packed. The rule must be to completely dissect out enlarged lymphatic glands which fail to quickly respond to treatment, removing capsules and glands. Climate is of very great importance. Osler sums up climatic necessities as "pure atmosphere, equable temperature, and maximum amount of sunshine." Open-air life is imperative. The patient must have a wellventilated sleeping-room, and his house should be free from dampness. Nourishing diet is essential. To gain in weight is a constant aim. Give meat, milk, cream, butter, and codliver oil, which may be administered in capsules. The oil is poorly borne in hot weather, during which it should be discontinued. Advancing doses of creasote, arsenic, quinin, and stimulants have their uses. (For treatment of tuberculosis of bones, joints, peritoneum, pleura, etc., look under special regional headings.)

Bier's Method.-A few years ago Bier set forth a new plan for treating tubercular lesions. It consists in causing venous obstruction and passive congestion. In the area of passive congestion the tissue-cells form antitoxins which kill the bacteria or attenuate their virulence. The treatment is founded upon the principle announced by Laennec, that "cyanosis is antagonistic to tubercle." The plan is applied particularly in joint-tuberculosis. An elastic band three inches broad is placed around the limb, above the seat of disease, and it is applied sufficiently tightly to cause congestion. Several pieces of lint ought to be interposed between the skin and the band. By applying a flannel bandage from the periphery to the lower border of the disease the congestion is limited to the area of trouble. The patient should wear the band continually and move about with it on. Some people wear it without any inconvenience, but others complain greatly after wearing it but a short time. Bier and others have reported cures. We have seen great mitigation of pain and temporary arrest in the advance of

the malady, but have never seen a cure brought about by the method.

Koch's Tuberculin.-The specific treatment by Koch's tuberculin or paratoloid has excited widespread interest. It has not fulfilled the expectations which many entertained, but does benefit some cases, notably lupus. A serious drawback to the value of Koch's tuberculin is that it often causes fever and inflammation to a dangerous degree. In some cases, as Virchow showed, it produces acute miliary tuberculosis. Koch's lymph is a glycerin-extract of a culture of tubercle bacilli, and the usual dose is I milligram, given hypodermatically into the back by Koch's pistonless syringe. After it has been used for a time the dose may be increased to 10 milligrams, or even much more. Bergmann gave I gram. Koch's lymph causes inflammation and necrosis of tubercular tissue by the action of certain antitoxins. Many cases it improves. Some cases it apparently cures, but the disease is apt to return. In pulmonary tubercle it must not be given if there be much fever or extensive consolidation. Chiene used tuberculin largely in joint-cases by giving two or three doses a day and increasing the dose. It is best to associate other treatment with the lymph. Tuberculin may be used for diagnostic purposes in animals. If tuberculosis exists, an injection of tuberculin produces a marked reaction. Czerny has shown that in renal tuberculosis in a human being bacilli are often absent from urine, but an injection of tuberculin will cause bacilli to appear plentifully. Koch has recently modified his tuberculin. He makes it as follows: dried cultures of bacilli are mixed with distilled water, and the mixture is agitated in a centrifuge. Two layers separate. The upper layer is the old tuberculin. The lower layer is the new tuberculin. The new tuberculin is given hypodermatically, at first in very small doses, but finally in doses as large as 20 milligrams. It is not to be given to far advanced cases or cases with much fever.

Hunter, of London, declares that Koch's lymph contains one principle which causes fever, another which causes inflammation, and a third which produces atrophy of tubercular foci without either fever or inflammation. This third desirable element he believes he has isolated in what is called a "derivative of tuberculin," a modified lymph. Some 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. The injection of serum obtained from animals re

fractory to tubercle has been employed, but Richet and Hericourt have seen no benefit from the plan. Maragliano, of Genoa, uses a serum which he believes can cure tuberculosis. He immunizes animals not by injection of living cultures, but by employing the toxic principles extracted from them. Progressive vaccinations immunize a dog. The serum of the animal is injected for the cure of tuberculosis in man or other animals. If injected with tuberculin, it neutralizes the general and local reaction of the latter agent. The serum has apparently benefited many cases, but is useless against mixed infections.1

XIV. 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).

Evidences of Rickets.-The condition is one of general ill-health; the child is ill-nourished, pallid, flabby; it has attacks of diarrhea and a tumid belly; it is disinclined for exertion and has a capricious appetite; it is liable to night-sweats and night-terrors; enlarged glands are often noted, the teeth appear behind time, and the fontanels 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, by the side of 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 imperfect ossification of the animal matter which is prepared for boneformation, 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 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. Bowlegs, knock

1 Brit. Med. Jour., 1895, ii., 444.

knees, and spinal curvature are usually rachitic in origin. The disease may be associated with scurvy, inherited syphilis, or tuberculosis.

Treatment. The treatment consists in open air, sunshine, salt-water baths, sea-air, fresh food (milk, cream, and meatjuice), cod-liver oil, syrup of the iodid of iron, arsenic, and some form of phosphorus. It is absolutely necessary to improve the primary assimilation.

Scurvy. This disease is rare to-day in adults, but was at one time very common among those who took long voyages, or who engaged in campaigns, or were the victims of sieges. Of recent years it is very uncommon, and has occurred chiefly among voyagers in the Arctic regions. It is a constitutional malady due to the consumption of improper diet, and especially to the employment of a diet characterized by the absence of vegetables.

The use of salt meat as a staple article seems to favor the production of the disease. Garrod considered absence of potassium salts to be the real cause. Absence of variety in diet, bad water, poorly ventilated quarters, and insufficient exercise favor the development of the disease.

The disease begins by weakness, drowsiness, muscular pains, and great susceptibility to cold. The skin is pallid or dirty white, and is occasionally mottled and often peels off. The pulse is excessively weak and slow. There is no fever. After two or three weeks the gums become tender, painful, and swollen, and bleed at frequent intervals; the breath becomes offensive, the teeth loosen and even drop out; subcutaneous hemorrhages take place, giving rise to petechiæ or extensive extravasations; the vision becomes dim, the urine becomes scanty and of low specific gravity; vesicles form, rupture, and give rise to bleeding ulcers, and ulcers likewise arise from breaking down of blood extravasations (American Text-Book of Surgery); hemorrhages take place into and between the muscles, and in severe cases beneath the periosteum and into joints, and blood may come from the nose, lungs, kidneys, stomach, and intestines. Deep hemorrhages are felt as hard lumps. Bleeding at an epiphyseal line may separate the epiphysis from the shaft. If an inflammation or ulceration arises at any point, fever is observed. It was observed in the expedition in search of Sir John Franklin that scurvy causes old and soundly healed wounds to ulcerate. Most cases get well under treatment, but complete recovery is not attained for a long time. is important to remember that though scurvy is rare in

It

adults, it is by no means uncommon in ill-nourished infants. The author has seen two cases in one of which a large subperiosteal hemorrhage was mistaken for sarcoma of the femur. It may exist with rickets.

Treatment.-Vinegar, lemon juice, onions, cider, nitrate of potassium, antiseptic mouth washes, strychnin, plenty of nourishing food, and whiskey or brandy. Secure sleep; treat ulcers by antiseptic dressings and compression.

Scurvy can be prevented entirely by securing a proper diet, and maintaining cleanliness and hygienic conditions (American Text-Book of Surgery).

The following agents are believed to be especially useful as preventives: fresh meat, lemon juice, cider, vinegar, milk, eggs, onions, cranberries, cabbages, pickles, potatoes, and lime juice.

Infantile scurvy may exist alone or with rickets. It occurs most often in the children of the rich, those who have been brought up on artificial foods. It occurs between the eighth and eighteenth month. The child is anemic, has gastro-intestinal disorder, spongy gums, weakness of the legs, general muscular tenderness, night-sweats, and often febrile attacks (Rotch). May have bleeding beneath skin (blue spots), bloody urine and stools, bleeding into joints, viscera, or muscles. A subperiosteal hemorrhage is very dense, is tender, is fusiform in outline, and does not fluctuate. The limb attacked is flexed, and the child will not move it. It is sometimes mistaken for sarcoma. Separation of epiphysis may result from hemorrhage between it and the bone. Treatment-Oranges, grapes, meat-juice, potatoes, nourishing food, tonics, and antiseptic mouth-washes.

XV. CONTUSIONS AND WOUNDS.

Contusions.-A contusion or bruise is a subcutaneous laceration, the skin above it being uninjured (as in the abdomen), or being damaged without a surface-breach (as in a part overlying bone), and blood being effused. If a large vessel is damaged, hemorrhage is extensive. 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 leukocytes are absorbed; the red blood-cells disintegrate, and the coloring-matter is widely diffused by the tissue-fluids (suggillation); and hemoglobin is changed into hematoidin, which crystallizes. In union with these