face, which when done two or three times over, apply plasters to the whole, formed in the following manner :-Take of the common yellow basilicon, ung. resina flava, according to the occasion; let it be mixed up with as much spirit of turpentine as it will take to make it of the consistence of a liniment, which, when spread upon thin oiled cloth, is to be applied to the part: the wax and oil of the basilicon will fill up the pores of the cloth so as to prevent evaporation, by which means the strong stimulant powers of the turpentine, or alcohol, or camphor, or all together, are so confined upon the surface as to excite the absorbents to the very increased action we wish; and, when this has taken place, the small quantity of oil is sufficient to preserve the cuticle in a pleasant state." (p. 132.)

KENTISH disapproves of frequent dressings; "for the very quick evaporation that takes place on exposing or uncovering the surface any time during the first four-and-twenty hours is pernicious; I therefore only dress the patient once a day even at first, unless in some instances. * ** ** But it will be better to allow him to remain for the first twenty-four hours without being disturbed; if the plasters are spread tolerably thick with the ointment, there will be no need of using any further means till the next dressing." The parts are to be exposed to the air as little as possible, and therefore the plasters are to be prepared before the dressing is commenced. The heated pure spirit is generally not again required; therefore, at the second dressing, the redness or seeming inflammation appearing less vivid, "proof spirit or laudanum with the coldness taken off, will be sufficient for this dressing, and the plasters immediately applied." Within the next twenty-four hours, "generally the appearance of inflammation has disappeared, and where there had been any small vesication in the first instance, there will be seen such a secretion of pus as may be noticed the second day after the application of a blister; the stimulants will now have performed their office, and, if continued on, they will produce unpleasant effects themselves, somewhat resembling the complaint they were meant to cure. * * * For which reason, as the equilibrium of action will appear nearly to be restored, it will now be necessary to apply less irritating substances; therefore, instead of basilicon made into a liniment with spirit of turpentine, it may be rendered into a proper consistence with camphorated oil; should even this be too strong and any appearance of irritation take place, the cerate with lapis calaminaris or GOULARD's cerate, will answer every purpose, and abate any irritation that may have arisen from the former applications. What I have found very effectual in such cases, is an ointment made with the addition of a scruple of flowers (oxyd) of zinc to an ounce of the white ointment, ung. cera; this, continued until the part heals, is in general sufficient; but, if the skin should, after healing, remain very tender and likely to crack, a liniment formed of lime water and linseed oil would be useful. I have frequently found much advantage from camphorated oil in this stage. These means properly attended to, and keeping the tender skin covered from the too great action of the external air, I have found effectual in curing, and quickly restoring the cuticle to a healthy state, after most severe cases." (pp. 133-36.)

Raw cotton has of late years been used in America. GIBSON (a) says:-"The best application I have ever tried is raw cotton, thinly spread out or carded, and laid directly over the burn. The value of this remedy was ascertained accidentally, a few years ago, (previous to 1824,) by a lady living in Hartford County, Maryland, whose child was scalded by boiling water, nearly over its whole body. The mother was carding cotton, in an adjoining room, at the time of the accident, and, having no medical assistance within reach, undressed the child as quickly as possible, and covered the whole burned surface with masses of the cotton. The effect was wonderful; for the child soon became perfectly quiet, fell asleep, and, upon removing the cotton, a few hours afterwards, no inflammation whatever could be perceived. Dr. DALLAM (b), to whom we are indebted for an account of this case, has furnished others of a similar character, in which the cotton proved equally efficacious, and my own experience enables me to confirm his statement of its usefulness. It is only, however, in the superficial burn that this remedy can be relied on. (p. 51.)

Dr. ANDERSON (c) is a strong supporter of the use of cotton in burns; he says:—“The utility of cotton is most conspicuous in simply vesicated burns, where one or at most two renewals of it are sufficient; and it is to these cases that I believe its application has generally been restricted. But I have used it in a great variety of cases, recent and old, vesicated and sphacelated. From the state of the parts after a deep burn, the

(a) The Institutes and Practice of Surgery, being an Outline of a Course of Lectures. Philadelphia, 1838.

5th Edition.

(b) On the Use of Cotton in Burns; in POTTER'S Medical Lyceum, p. 22.

(c) On the Treatment of Burns; in Glasgow Medical Journal, vol. i. 1828. 8vo.

cotton generally requires renewal about every six or eight days, until the sloughs have long separated and the discharge has been diminished. The comfort enjoyed during such intervals should go far to recommend this practice, even if, in other respects, it had no advantage over that by a daily renewal of the dressings. But I am now quite satisfied that a persevering use of this remedy, even in the chronic state of burns, and in many other ulcerations, is in every respects preferable to the practice usually adopted. (p. 211.) Some care is necessary, both in preparing and in applying the cotton. For this purpose it should be finely carded, and disposed in narrow fleeces, so thin as to be translucent, by which means it can be closely applied in successive layers, and is thus made to fill up and protect the most irregular surfaces. The burnt parts, if vesicated, are to be washed with tepid water, and the fluid evacuated by small punctures; or, if more deeply scorched, they may be bathed with a spirituous or turpentine lotion. The cotton is then applied, layer after layer, until the whole surface is not only covered, but protected at every point, so that pressure and motion may give no uneasiness. On some parts it will adhere without a bandage, especially when there is much discharge; but, in general, a support of this kind is useful. Where the vesications have been broken, and the skin is abraded, or where there is sphacelus, more or less suppuration always ensues, and in such cases the discharge may be so great as to soak through the cotton and become offensive, particularly in summer; so that it may be necessary to remove the soiled portions. This, however, should be done as sparingly as possible, taking care to avoid uncovering or disturbing the tender surface. (pp. 213, 214.)

There appears," ANDERSON further observes, " to be a twofold effect from this kind of treatment. The primary effect arises from the exclusion of the air and the slow conducting power of cotton, by which the heat of the part is retained, whilst a soft and uniformly elastic protection from pressure is afforded. The secondary effect depends entirely on the sheath or case formed by the cotton absorbing the effused serum or pus, and giving the best possible substitute for the lost cuticle. But, in order that the full benefit may be derived from this substitute, and to ensure an equable and continued support to the tender parts until the new skin is formed, it is absolutely necessary that this new or cotton cuticle, as it may be called, should not be removed except under particular circumstances, until the real cuticle is sufficiently formed to bear exposure. (pp. 217, 218.)

The use of flour as an application for burns was, I believe, first recommended by Dr. WARD (a), formerly one of the surgeons of the Manchester Infirmary, who appears to have employed it accidentally at first; for, finding a young woman who had been scalded from the elbow to the fingers' ends, screaming with pain and shivering as if in the cold stage of an intermittent whilst her mistress was rubbing in goose grease, preparatory to the application of scraped potato, he absorbed the grease with soft linen, and then with a flour-dredger, which happened to be at hand, sprinkled the scalded parts as completely and expeditiously as he could, which almost immediately and entirely relieved the pain. The same application was used by WARD in several other cases (p. 619.) His mode of proceeding he thus describes: The first object will be, (after having laid the patient upon a bed or sofa,) without a moment's loss of time, to take off the clothes and apply bread flour, by means of a common kitchen dredger, plentifully, and as expeditiously as possible, to the whole of the burned or scalded surface, and this being properly and sufficiently done, carefully applying clean dry linen eloths immediately over the flour, and such bed-clothes or other coverings as may be required to keep the patient comfortably warm, but not too hot." He strongly advises "avoiding the application of liquids of whatever kind, including oil, and liniments, ointment, and salves containing oil, all of which are extremely pernicious." If the pain be removed by this first application, it is advisable that the patient should go to sleep, even though he have no nourishment. "If pain return we must commence by removing the linen coverings or bandages from those parts where the pain is the most considerable, without attempting to remove any of the flour previously applied, except such portions as do not adhere, and then proceed as before to apply flour equally and copiously to the painful parts, by means of the dredge, which is the easiest and best method of effecting it. It would also be a good general rule, particularly at the first and several of the succeeding dredgings or sprinklings, to continue the process for a certain time (longer or shorter, according to the extent of the violence, and the degree of pain complained of) after the parts become easy, (with a view to keep them in that state as long as possible,) and steadily to persevere in it either until the last-mentioned object be attained, or the parts affected shall have received a coating or covering of this invaluable article of fron a quarter to nearly half an inch in thickness, and then apply

(a) A New Method of Treating Scalds and Burns. Two Papers; in Lancet, vol. ii. 1828.

the bandages, as before: and, secondly, not to disturb those places which still continue easy in consequence of having undergone one or more sprinklings or dustings, until the return of pain or uneasiness shall indicate the necessity of repeating it. And, in this manner we must proceed the first two or three weeks, or until that period shall arrive when it will be necessary to make some addition to the flour." (p. 176.) This addition consists of one portion of calamine powder to three of flour, gradually increasing the calamine till the proportions are equal, and then by degrees diminishing the flour till the calamine alone is applied, except some calamine ointment with an increased quantity of the earth, spread very thinly on linen, and laid over the powder. A moderate diet is allowed, commencing first with milk, puddings, broth, and soup. Medicines are to be used sparingly; but, if sleep cannot be obtained, then opiates,-DOVER's powder, perhaps, in preference to laudanum, in proper doses every four or six hours, rather than one large dose; or an opiate friction on any uninjured but sufficiently extensive part to be effectual. WARD'S explanation of the modus operandi of flour is, "that, by its instantaneous operation as an absorbent powder, in allaying the irritation, and partly by its coldness diminishing the temperature of the inflamed parts, it immediately arrests the rapid progress of the inflammation, and forms a fit medium or covering to prevent the access of the atmospheric air to a part of the body which is at all times peculiarly susceptible of its action (especially upon a large and extended surface of it) but which is now rendered a thousand times more susceptible than before.

MARSHALL (a) makes the following observations on the modus curandi of the remedy:-"This mild substance," says he, "is doubtless pre-eminent to all others hitherto in use, by imparting immediate ease to the inflamed and irritable surface; it rapidly heals by the scabbing process, in uniting with the discharge from the abraded cutis; and almost instantaneously forms a temporary semi-transparent covering, thereby assisting the natural functions in restoring the epidermis. The advantage becomes evident by stopping a profuse discharge, and the tedious progress of ulceration. That remarkable substance the animal (vegetable?) gluten, peculiarly contained in wheat, seems, in this instance, to assist the rapid regeneration of the scarf-skin, and thus protects the cutis and rete mucosum. The surface of the body being wonderfully supplied by the extension of the cutaneous nerves, in the form of a soft pulpy membrane, somewhat resembling the expansion of the optic nerve on the retina, readily affords, it is presumed, an explanation of the great violence offered to the system in all cases of extensive burn or scald. The topical remedy is equally suitable to either of these accidents, and perhaps, eventually, will be found useful in many other cutaneous affections. *** When the flour has formed the artificial covering, the further application becomes comparatively superfluous, which is perceived by its rolling off." (p. 298.) Beyond a single slight case, which did very well, I have no personal knowledge of the effects of flour; but I know some of my friends think it a good application.-J. F. S.

On the primary treatment of these accidents HUNTER says:-"Whatever will abate inflammation arising from accident, will have the same effect upon a scald or burn; and, from the diversities of applications, we have opportunities of knowing the best. Oil was long an application, but which has no virtue; spirits have also been long applied, and with very good effect. The common application, which is a soap made with lime water and oil, seemed to answer better; and now vinegar (b) is strongly recommended, and I think with justice as far as I have seen." (p. 218.) The best secondary treatment HUNTER considers to be that by scabbing, of which he says, "the mode of assisting the cure of wounds by permitting a scab to form, is likewise applicable, in some cases, to that species of accident where the parts have not only been lacerated, but deprived of life.” And then observes:-" This practice is the very best for burns or scalds, after the inflammation has either been considerably prevented, or subdued, by proper applications or by time, for which there probably are more remedies than for an inflammation arising from any other cause, as if there was something specific in such causes." (p. 217.)

The two French surgeons, BRETONNEAU of Tours and VELPEAU, who have been already cursorily noticed as employing pressure in pseudo-erysipelas, have also recommended it in the treatment of burns. BRETONNEAU (c) advises the application of circular bandages, either dry or moistened with a discutient or narcotic wash, the vesicles, if any, having been emptied by one or more punctures. He considers that the pressure, besides preventing exhalation of the serosity, keeps the cuticle on the rete mucosum, and thus

(a) On the Treatment of Burns; in London Medical and Physical Journal. New Series, vol. vi. 1829.

(b) This was CLEGHORN, the Edinburgh Brewer's
(c) Already quoted,

Treatment; for which see his Account of a Method
of Curing Burns and Scalds, in three Letters to JOHN
HUNTER; in Medical Tracts and Observations,
vol. ii. London, 1792.
par. 91, p. 108.

protects it from the air and external agents. But, if the burnt part be stripped of its skin, oiled silk carefully fitted is to be first applied. VELPEAU (a) recommends strongly the employment of compression in burns, by the application of diachylon plaster spread on strips of cloth, although he very candidly admits that further experience is yet requisite to perfect this mode of cure. He lays great stress on the composition of the plaster; that it should contain neither too large a proportion of grease nor of diachylon, but that there should be a pretty large quantity of litharge, and that it should be of a softish consistence, as the effect is produced not merely by the compression, but varies according to the composition of the plaster." (p. 187.) Adopting the four degrees of burns mentioned by our author, VELPEAU says that

1. In those of the first degree characterised, by erythema or even tumefaction, with itching or slight pain, all modes of treatment succeed, and that it is not, therefore, in this case he hopes particularly to recommend his own. 2. That, in those of the second degree, characterised by the coming off of the epidermis or phlyctanæ, without alteration of the mucous body, the effect of the straps shows better. 3. That, in those of the third degree, that is to say, those where the mucous net-work has been partially destroyed, and in those of the fourth degree, where the skin is completely converted into eschar, his mode of treatment is almost indispensable." And he then proceeds :-" In burns of the first degree very good results are obtained from cold water, camphorated brandy, solutions of chlorures, and compression especially, but that the efficacy of the latter varies according to its application. Thus, I am persuaded that the straps are preferable to simple compression, because their employment is easier; because they do not fall off, and may remain a much longer time; that in those of the second degree, cold water, refrigerants, chlorurated solutions, especially, may cure, the phlyctænæ being first removed; for I hold much with this little operation, without which I never employ any application." (p. 186.) His mode of proceeding is thus described:-"1. Strips of cloth spread with diachylon are to be applied upon the injured surface. 2. Indispensable that they should be applied very equally on every part of the wound to prevent strangulation. 3. They must be so applied as not to loosen, and it is therefore necessary they should make at least one turn and a half round the leg. 4. When the regions upon which they are applied are irregular, the hollows must be filled with charpie or cotton; thus, for instance, if there be a wound on the foot, the sole is to be thus padded, so as to form a rouleau. 5. The strips require different directions according to the form of the limb on which they are applied; thus, on the leg, which forms a cone, they must be placed spirally, commencing from below upwards. 6. Each strap should cover two-thirds of the width of that below it, to render the compression uniform." (p. 187.) The advantages derived from this plan of treatment are, according to VELPEAU's views, the following:

"1. In burns of the first and second degree, the application is followed by a more prompt cure, i. e., it is completed after one or two applications at most, or in a day or two. 2. That in those of the third degree three or four applications are needed, which require eight days at most, whilst other modes require fifteen days or a month. 3. That the cure of burns of the fourth degree depend on the depth of the wounds." (p. 186.)

In now proceeding to give an account of my own mode of treatment, I would premise that HENRY EARLE'S observations on the careless mode in which clothing is too commonly removed after burns and scalds, are well worthy attention. "It unfortunately happens, too frequently," says he, "under these circumstances, that the first thing done is to remove the stocking, which often brings away with it large portions of the cuticle, leaving the inflamed cutis denuded; for, although in these cases sufficient time may not have elapsed for the occurrence of inflammation and the production of vesications, yet the application of the hot liquid will cause sufficient separation between the dermis and epidermis to cause it to come away on pulling off the stocking. If, instead of this forcible removal of the clothes, such limbs were to be immediately immersed in the coldest water, this most serious result would generally be prevented. The same clothes which were the medium for retaining the heat may be made the readiest means of abstracting it and of diminishing the inflammation; and, should it become necessary, in consequence of the formation of vesicles, to remove them, they should be cut away with the utmost caution, and the vesicles preserved unbroken; by which the serious consequences which follow the exposure of the highly inflamed cutis, will be prevented." (p. 301.)

The justness of these observations, as regards not merely the increase of the patient's sufferings, but also as to rendering his situation much more dangerous, especially if the vesications be large, must be sufficiently obvious. It is, therefore, scarcely necessary to (a) His Clinique-Brûlures, Traitement par les Bandelettes de Diachylon; in Lancette Française, vol. ix. 1835.

observe that the removal of the clothes should be effected with great carefulness, and EARLE's advice as to thoroughly soaking them in water, either warm or cold, according as the practitioner may prefer applying his remedies in one or other state, is very excellent and highly deserving of being acted on. After soaking, it is better to cut the clothes through with scissors, till the whole will drop off or the patient can be lifted out of them, rather than to drag him about as is frequently done for the purpose of saving the clothes at the expense of the patient's skin.

My own observation and experience lead me to consider the local treatment of scalds and burns as very simple, the great object in view, if there be vesication, to whatever extent, without death of the skin or subjacent parts, being to defend the exposed highly sensible surface of the true skin from the air, by affording it an artificial sheathing, and thus relieving the irritation of the nervous system. If the vesications be unbroken, I think it best to leave them undisturbed, as adhesive matter is speedily effused over the surface of the true skin, directly after the effusion of serum has ceased; an observation which may be daily made in watching the progress of an artificial blister. After a time, about forty-eight hours, the serum within the vesication becomes irritant, and this circumstance is indicated by the margin of the uninjured skin bounding it presenting a red line. The skin must then be punctured in several parts, varying according to the size of the blister, and near its base, so that the serum may escape, which it generally does slowly, the serum now holding in solution a large quantity of albumen, and not unfrequently seeming as it were contained in large cells, resembling those containing the vitreous humour of the eye, although much larger. If when the patient be first seen the blisters are found already burst, the cuticle should not, on any account be removed; for, wherever it covers it forms too good a sheathing to be taken away. In either of these cases I generally first apply linen soaked in warm lime water and linseed oil, keeping it continually wetted with a sponge, without removal for forty-eight hours, after which, suppuration having by that time usually commenced on those parts of the wound which require it for their cure, I have the lime water and oiled cloths gently removed, and all the injured parts, whether to little or great extent, enveloped in bread and milk poultices, which are renewed twice or thrice a day, according to the discharge. This application is very bland, a delicate film from the coagulable part of the milk, and the mucilaginous portion of the bread soon covers the exposed tender surface, or keeps the remaining cuticle supple and moist, thereby rendering the patient extremely comfortable, at the same time, also, that he is kept very clean, and free from offensive smell, which are points of extreme importance in the treatment of scalds and burns, as regards both the health and comfort of the patient. I rarely find it necessary to employ any other treatment; for, if the accident be not extensive, in a few days it heals, and, if it be more spread, though the time of cure is necessarily longer, yet, the same result ensues. Sometimes, however, more to relieve the patient from the strict rest which the poultice requires than for any other cause, after five or six days, the poultice is left off, and zinc ointment spread on lint or soft linen is applied.

If the true skin, or together with it more or less of the subjacent parts be destroyed, I still consider a poultice the best, most cleanly, and most comfortable application, made either simply of bread and milk, or bread and linseed meal, which are to be continued till all the sloughs have separated and granulations have been fully produced. After which wax and oil, or zinc ointment, or calamine ointment, spread on lint, may be gently bound on with a roller.

If the granulating surface be very extensive, it is generally long in cicatrizing; the granulations become pale and flaccid, or even disappear, and the pus thins and becomes limpid on the slightest disturbance of the digestive organs, thus putting a temporary stop to the cure; but, the irritation removed, things revert to their former channel, and healing is resumed. These alternations occur frequently in the course of a long cure, and must always be carefully watched and tended, as often the suspension of suppuration for a few hours causes determination to other parts, as the brain, lungs, and mucous membrane of the bowels, and the patient is cut off at the very time when there is every reason for his recovery.

From the observation I have made of the various modes of treating scalds and burns, it appears to me that it is matter of little consequence what the primary application is, provided it be warm or capable of preserving the warmth of the part. Cold washes I do not approve of, especially if the injured surface be large, as then a considerable portion of the body or limbs is suddenly cooled, and very frequently severe shivering is excited which adds much to the patient's discomfort; or if, as is often the case, the patient be already shivering, that condition is increased by the application of cold.

If stimulants be at first applied according to KENTISH's plan, or, if cold washes be