with the nitrate of silver some inches above. I have sometimes seen the erysipelas extend up to the belt and there stop; at other times I have observed it move on without having met with any check. I am therefore doubtful of the efficiency of the nitrate of silver; but, if used, it should be carefully applied, even to blistering the skin, otherwise it is certainly useless.-J. F. S.]

92. As various also are the opinions as to erysipelas consequent on wounds, (Erysipelas traumaticum,) in which the most opposite fomentations, blisters, incisions and scarifications, cauterization with the red-hot iron, (LARREY,) antiphlogistic treatment, emetics, and so on, have been recommended. If the above-described different kinds of erysipelas and pseudo-erysipelas be borne in mind, and, if it be remembered that the traumatic erysipelas, which in four or five days accompanies wounds, is produced by different causes, as too great irritation of the wound by improper bandaging, foreign bodies, the application of greasy, too stimulating or too hot softening remedies, cold moist air, a bruised and torn condition of the wounded part, wounds of fibrous structures, gastro-biliary affections, mental excitement, improper food, and the like, it may be easily perceived, how a proper observation of the various causes can alone prevent a merely routine treatment of so important a disease (a).

II. OF BURNS.

CLOWES, WILLIAM, Aprooved Practise for all Young Chirurgians concerning Burnings with Gunpowder and Wounds made with Gunshot, &c. London, 1588. 4to. IBID., A Profitable and Necessarie Booke of Observations for all that are burned with the flame of Gunpowder, &c., London, 1596. 4to.

KIRKLAND, T., Abhandlung von Brandschaden. Nurnb., 1769. 8vo.

KENTISH, EDWARD, M.D., An Essay on Burns, principally upon those which happen to Workmen in Mines from the Explosions of Inflammable Air (or Hydrogen Gas), &c. London, 1797. 8vo.

IBID., A Second Essay on Burns. Newcastle-upon-Tyne. 8vo. 1800.

EARLE, JAMES, Essay on the Means of lessening the Effects of Fire ont he Human Body. London, 1799.

MARJOLIN ET OLLIVIER, Article Brûlure, in Dictionnaire des Sciences Médicales.

MOULINIE, Dissert. sur la Brûlure. Paris, 1812.

DICKENSON, NODES, Remarks on Burns and Scalds, &c. London, 1818. 8vo.

DZONDI, K. H., über Verbrennungen und das einzig sichere Mittel, sie in jedem Grade schnell und schmerzlos zu heilen. 2nd Edit. Halle, 1825.

BODIN, Essai sur la Brûlure. Paris, 1830.

DUGUERON, Dissert. sur les Brûlures. Paris, 1830.

DUPUYTREN, Leçons Orales de Clinique Chirurgicale, Paris, 1832, vol. i. p. 413, vol. ii. p. 1.

93. Burns (Combustiones, Ambustiones, Lat.; Verbrennungen, Germ. ; Brûlures, Fr.) are produced by fire or heated substances touching our bodies. The action of caustic substances, especially of the concentrated mineral acids, corresponds precisely with that of fire. According to the degree of heat, in fluids therefore according to their consistence and capacity for heat, according to the duration of the contact and the delicacy of the part touched, different degrees of burns are produced, which may be thus distinguished: 1. as superficial inflammation (Erythema ;) 2. as more

(a) Compare LARREY, Clinique Chirurgicale, vol. i. p. 21; BALLING as above.

severe inflammation with rising of the cuticle into blisters (Vesication ;) 3. more deeply penetrating, higher inflammation, with the destruction of the cuticle and of the mucous net; 4. gangrenous destruction at different parts and to various depths.

Degrees of burns are variously distinguished, as they are considered not merely as to their intensity, but also with reference to their spreading into deeper parts. Many point out but three degrees. DUPUYTREN has described six; of which the latter, however, only differ in proportion as the gangrenous destruction is more or less deep, or involves the whole bulk of the limb. The four above-mentioned degrees are based on the corresponding steps of inflammation, viz., the erythematous, exudative-inflammatoryvesicular, the phlegmono-suppurative and gangreno-sphacelous. According to the variety of causes producing burns are these degrees of burning frequently blended with each other; for instance, in burns with hot fluids.

94. The first degree of burn, arising from hot vapour, from the momentary or lengthened touch of a more or less hot body, produces a bright uncircumscribed redness of the skin, as in erysipelas, which for the moment disapppears on pressure of the finger, without swelling, and is accompanied only with increased turgescences of the skin and a little pain. Febrile action only sets in if this degree of burn be much spread and in sensitive persons. The redness of the skin either disappears after some hours or days, when the cuticle scales off.

95. In the second degree, which is most commonly produced by hot fluids, the cuticle rises either at once or gradually into larger or smaller blisters, filled with clear or yellowish fluid, the redness and swelling of the skin is more distinct; the pain severe, burning; and, according to the degree of these appearances and the extent of the burn, do febrile symptoms set in. These blisters either shrivel together and dry, the fluid being absorbed and the skin thrown off, or, if they burst and are opened, the fluid is discharged, the blister falls together, dries, and after some days either a new cuticle is produced or the exposed part suppurates. The healing leaves no scar.

96. The third degree of burn is usually produced by the flame of fire or by the lengthened touch of hot bodies, especially of hot fluids, and is characterized by gray, yellowish, or brown spots, which are thin and soft, insensible to light pressure, but are painful if the pressure be increased; at the same time generally appear blisters full of brownish or bloody fluid; the surrounding parts are very red and much swollen. The general reaction corresponds to the degree of the inflammation. After six or eight days, and frequently later, the remains of the destroyed cuticle and mucous net are thrown off, and the cure is effected by granulations and the formation of a white glossy scar.

97. In the fourth degree of burn the destruction penetrates either through the entire thickness of the skin and cellular tissue, or deeper into and through the muscles to the bone, or the whole part is destroyed and charred. This degree is produced by long contact with fire, red hot or molten metals, boiling fluids. The sloughs differ in thickness, are completely insensible; soft, gray, or yellow if produced by hot fluids; brown or black, dry, hard, and sounding when struck, if caused by fire or dry hot bodies. In the immediate neighbourhood of these sloughs the skin is drawn into radiating folds; the surrounding parts are extremely red and swollen, very painful, and frequently beset with blisters. The slough is thrown off by the suppuration which takes place around it, and a more or less deep suppurating space is produced, which commonly has a

much larger extent than the slough, because in consequence of the severe inflammation its immediate belt is destroyed by gangrene. The granulations most usually are developed very quickly and luxuriantly, the edges quickly draw together, and shapeless, hard, contracted, tough scars are produced, whereby the direction and motion of the part is often changed and impeded, and the latter even perfectly destroyed. After the throwing off of a part which has been entirely charred, a more or less uneven stump is produced.

98. More or less severe symptoms ensue according to the different degree and extent of the burn, according to the importance of the burnt part, and the constitution of the patient, and not merely does the degree, but also the extent of the burn, determine its danger. In the first two degrees the inflammation is easily resolved, and only if it affects a large extent of the body, and still more in the higher degrees, does febrile reaction set in, when, on account of the disturbed functions of the skin and the changed relations between the external and internal skin, the mucous membrane of the intestines is quickly affected, and uneasiness, loss of sleep red dry tongue, nausea, vomiting, high nervous excitement, delirium, and the like come on. From the severity of the pain cramps and convulsions occur, especially in sensitive persons. In extensive burns death may ensue rather suddenly from the greatness of the pain, from the quick stopping of the functions of the skin, from the excessive flow of blood to the internal parts where on dissection either no internal derangement is seen, or where a gorging of the brain and mucous membranes with blood and even effusion into their cavities is observed; or from the severity of the fever, especially if accompanied with inflammation of internal parts, of the stomach intestines, brain, more rarely of the lungs and of the pericardium; or from the very copious and continued suppuration, by which the powers are exhausted. The production of unsightly hard scars, or the growing together of neighbouring parts, may cause disturbance or complete stoppage of their functions.

[Burns, from whatever cause, are generally more dangerous than scalds, as they are rarely unattended with destruction of the skin and subjacent parts, whilst, on the contrary, scalds more usually produce only vesication. If, however, a person be completely immersed in boiling water, even for two or three minutes, of which I once saw a frightful instance, of a dyer who fell into his copper, he will be destroyed in ten or fifteen minutes. But I have several times, on the contrary, seen persons, whose entire surface has been charred by fire, live for many hours. This remarkable difference may, perhaps, be accounted for by presuming that the hot water, passing through the mouth and nostrils into the pharynx, causes speedy effusion into the loose cellular tissue connecting the skin with the laryngeal cartilages, and so, by narrowing and closing up the aperture of the windpipe, producing suffocation.

Both burns and scalds, however, are dangerous, more in reference to the part which they attack, than the extent of surface they injure; thus, scalds or burns on the chest and belly especially are far more dangerous than on the limbs, although the injured part be twice or thrice as extensive; and children who are burnt or scalded on the chest most commonly die in two or three days after the accident; in a few instances they may live a week, but they rarely ever recover. I recollect only a single instance of recovery, after severe burn on the trunk, in a child about six years old, in whom the whole front of the belly and flanks were burnt and a considerable part of the skin destroyed. I do not recollect to have observed convulsions in these severe cases, as mentioned by our author and other writers; but, if they be fatal in a few hours, the patient generally, almost at once, drops into a state of stupor from which he never after rouses; and examination after death shows the brain loaded with blood, or, if life be prolonged, effusion of serum is observed on the membranes, and in the cavities of the brain, and, less commonly, also in the serous bags of the chest.-J. F.S.]

99. The slighter degrees of burn require merely the application of cold water, or the dipping the part in cold water; all other of the prescribed remedies, lead wash and so on, act only by their coldness. If fever be present the internal use of antiphlogistic remedies and a suitable diet must be combined with the local treatment. If the cuticle have been raised into blisters, they should be opened with a fine lancet, without removing the skin, so that the contained fluid may escape. If they be small, they often, under the use of cold, fall together and dry. If the part be deprived of its cuticle, generally it will not bear the cold application, which irritates, and increases the pain; but simple, mild, soothing remedies, mucilaginous, mild poultices or fomentations, a liniment of pure oil and yolk of egg, fresh butter, and other mild salves may be spread on pieces of soft linen, which should be applied over the burnt part, and often changed, or they should be frequently sprinkled with the remedies, to prevent their drying and sticking, so as to soften and cool by their frequent renewal. Cold is always to be applied to the neighbourhood of the parts deprived of their cuticle. When suppuration is established, and the extreme sensibility of the affected part reduced by the use of mild remedies, astringent and drying applications are to be gradually had recourse to: linseed oil, with lime water, zinc ointment, and so on. Lead ointment is said to produce ugly ill-shapen scars, which, however, I have not observed. If much proud flesh occur, it must be kept down with nitrate of silver. If mortification be produced at the instant of the burning, cold application, or, if the parts are very sensitive on account of the destruction of the cuticle, merely softening and soothing applications must be used till the slough is thrown off by the suppuration, when the remedies aforesaid must be employed. Sloughing rarely extends in this case, if not accompanied by deterioration of the juices. In other respects its treatment, even when resulting from the inflammation depending on the burn, is to be after the same general rules laid down for gangrene.

The remedies especially recommended for burns are very various, and in part completely contrary to each other in their operation. 1. Popular remedies, such as poultices of scraped potato, apples, moist earth, and so on, which are cooling by their proper renewal. 2. Applications of spirituous fluids, æther, alcohol, brandy and so on, if used cold, act also coolingly by quick evaporation; if warm, they can only act as counter irritants but all burns in which the rete cutaneum is exposed must be protected from irritation. 3. The burnt part is brought near to the fire immediately after the burning. 4. Wraps, by which the burnt parts are kept perfectly closed against external influences. The overlaying of fine cotton or wadding, to be kept moderately tight with bandages till it falls off. If blisters are present, they must be first punctured. The strewing with flour and bandaging with dry linen. If pain recur, the linen should be removed and the flouring repeated again and again till it is a quarter or half an inch thick. In very severe burns, after a fortnight, a fourth of calamine powder is added to the flour and applied moist. Covering with chalk, smearing with ambervarnish or tragacanth mucilage spread on blotting paper or fine linen. The watery solution of lunar caustic, recommended by FRICKE, operates in a similar way, by defending the sensitive surface and furnishing it with a covering beneath which speedy healing takes place. In like manner is the operation of kreosote to be explained, from which, when diluted with water, or mixed with grease as a salve, I have frequently observed the best consequences. 5. Various ointments for burns, consisting of fat, butter, wax, cream, and the like. LARREY forbids all cold and cooling remedies, and uses saffron ointment and ointment of styrax. 6. Solution of chlorate of lime, wherewith the bandage is to be frequently moistened during the day, causes a slight itching for about ten minutes, and is, according to LISFRANC, useful in slight degrees of burn, producing new skin in twenty-four hours; in higher degrees the suppuration is diminished and improved.

Much difference of opinion has existed and still exists among English surgeons, as to

the choice of remedies for burns and scalds. Whilst some prefer moist applications, cold or warm, either as washes or liniments and ointments, others advocate the use of dry substances, as cotton or flour and the like. I shall first mention some of the more prevalent plans of treatment, and afterwards describe my own ordinary practice, without, however, claiming for it any great degree of originality.

JAMES EARLE was the principal supporter of cold moist applications in form of very cold water or even ice, pounded and applied on clothes or in a bladder. HUNTER observes:- Cold lessens all inflammations, and is a very good application where it can be applied; but it cannot be applied so universally as others. However, cold has this disadvantage, that the pain, although removed while under the application, occurs with double force when it is removed, much more than from any of the applications; and the reason is evident, for, as the warmth returns, the pain is increased by the warmth, even in sound parts." (p. 218.) HENRY EARLE (a), also, although he advocates both cold and warm applications on certain conditions, notices the objections which exist in reference to the use of cold, at the same time that he mentions its advantages. He says:-"The advantages of the plan (the application of cold) are, that it may generally be resorted to without delay, and that it has the effect of affording immediate relief. The disadvantages attending it are, it is necessary to continue or renew the application of cold for a considerable time, as the heat and pain will return, unless the diminished temperature be steadily maintained. On this account it is that, in certain delicate constitutions, and especially when the injury extends to the chest or trunk, this cooling plan of treatment cannot be employed without risk. (p. 301.)

The treatment recommended by KENTISH (b), and consisting of the primary application of warm and stimulating remedies, is generally practised in the coal districts of the North of England, and therefore, if for no other reason than that it has been there found successful, is well entitled to notice. I have had a little experience of its effects, and do not think it less advantageous than most other plans of incipient treatment, which is the principal point of difference in the practice. KENTISH's theory of the treatment of burns and scalds is founded on the mode of treating frost-bite, the very reverse of which he considers, with a fair show of reason, is here indicated. Nor are his views to be set down as "visionary, as amusing the fancy, but never capable of improving the judgment;" nor are they "nearly unintelligible, nor unsupported by any sort of rational evidence," as they have been asserted to be by SAMUEL COOPER. The question "the effects of heat above the freezing point, carried to the extent of what is termed burning," being the converse of its effects "below the freezing point, commonly called the effects of cold," it will be, on the whole, more convenient to leave the discussion of till we treat of frost-bite.

KENTISH'S object consists in "restoring the unity of action," as he calls it, in these "local injuries from increased action," first, by gradually diminishing the excitement or action of the part; and, secondly, by increasing the action of the system to meet the increased action of the part; holding this law of the system in view, that any part of the system having its action increased to a very high degree, must continue to be excited, though in a less degree, either by the stimulus which caused the increased action, or some other having the nearest similarity to it, until, by degrees, the extraordinary action subsides into the healthy action of the part." With this view, holding the part to the fire seems the best mode of relief; but, as parts of the body are injured where this cannot be done, the most stimulant applications must be had recourse to; for, in this class there is little fear of any of them being greater than that which originally caused the accident; the strongest rectified spirits made still stronger by essential oils; add to which they may be heated as much as can be suffered on the sound parts; these, and many more applications of the same class will give the speediest and most effectual relief. These are only to be continued for a certain time, otherwise they may afterwards cause the very ill they were given to cure; and should be succeeded by less stimulant applications, until the parts act by the common natural stimuli. The internal mode of relief will be to give those substances which soonest excite the system to great action, such as æther, ardent spirits, opium, wine, &c., by which means the solution of continuity of action is allowed to continue the shortest time possible, and the unity of action restored, which constitutes the cure." (pp. 112-14.)

The mode in which KENTISH Sets about the primary dressing of burns is as follows:"Take a teacup and put some of the best rectified spirit of wine, or spirit of wine with camphor, or spirit of turpentine, into it; then place it in a basin of hot water, so as to heat it to what you can bear with your finger; then, by means of a rag dipped in this, or a probe armed with a good deal of lint, wash and bathe the whole of the injured sur(a) Clinical Lecture on Burns; in Medical Gazette, vol. v. 1830. (b) On Burns, &c. VOL. I. I