of laudanum is best. If the erysipelas run into ulceration or gangrene, attention must be paid to giving free escape to the ichor; the general and local treatment must be regulated, as before mentioned, according to the character of the fever, and the rules given in reference to abscess and gangrene, and clearance of the bowels, must be especially remembered.

[The local treatment of erysipelas is very simple; warm or cold washes, as may be most agreeable to the patient's feelings, consisting of water with a little spirits of wine, are best, and I think preferable to either warm or cold lead wash, which renders the cuticle harsh and unyielding.

If there be much tension of the skin, the practice recommmended by DOBSON of making a dozen or twenty punctures with the point of a lancet is very beneficial, and agreeably relieves the hide-bound sensation which the patient feels.-J. F. S.]

89. In idiopathic erysipelas the treatment must be guided according to the degree of the inflammation. General antiphlogistic treatment is rarely necessary in this case; usually the application of leeches and of cold water or lead wash are sufficient for resolution.

[Leeches should never, under any circumstances, be applied locally, as the irritation resulting from their use itself frequently excites erysipelas or rather erythema. If absolutely requisite, puncture with the lancet is to be employed.-J. F. S.]

cause.

90. In erythema consensuale the treatment varies according to its original If it depend on the tension of aponeurotic expansions, incisions, warm bathing, friction with mercurial ointment, warm fomentations and poultices must be applied. If the erysipelas appears only as a reflection of deeper disease of the periosteum, of the tendons, or of cellular tissue, so long as the disease continues purely inflammatory, abstraction of blood, leeching, applications of cold lead wash and free mercurial friction, and, in metastasis especially, mercurial laxatives and warm aromatic fomentations, must be used; in gastric symptoms, with loaded tongue, heartburn and the like, a vomit should be first given, by which principally the course of the disease is rendered less severe. But, if gangrene or ulceration have occurred in the deeper parts, and there appear a spot particularly discoloured or fluctuating, it must be opened and the wound dilated with the bluntended bistoury upon the finger in every direction where the destruction of the cellular tissue has occurred, in order to discharge the pent-up ichor and the often large pieces of completely dead cellular tissue. The further treatment consists in supporting nature to throw off the destroyed parts, to sustain the sinking powers, and to produce good suppuration. According to RUST, there may be applied locally bark, camphor, myrrh, charcoal, camomile flowers, turpentine oil, camphorated spirit, pyroligneous acid, spirituous aromatic fomentations, and so on; internally, powerful tonic remedies are to be used in connexion with mineral acids, and, if thereby a good suppuration is produced, the healing may be aided by the application of a moderately compressing bandage. I have, however, noticed, that under this stimulating local treatment, the destruction and unhealthy suppuration as well as the general irritation have increased, and that by the use of warm fomentations and a suitable general treatment improvement has been much more quickly produced; I, therefore, only use warm applications locally. In great hardening of the skin and of the underlying cellular tissue, I have always effected a perfect resolution by mercurial infriction and malt baths.

[Neither leeches, cold washes, nor mercurial friction are, according to my experience, of any material advantage, and therefore hurtful, as causing waste of time. The best

local treatment, and which I almost invariably adopt, is, when the skin is tense, shining, and deep red, to make several incisions, according to the extent of the disease, from an inch and a half to three inches in length, which I think preferable to very long cuts, just through the skin into the cellular tissue, which should be so disposed that every four should have interposed between them a sort of diamond-like space, and thus, when several cuts are made, the skin has a net-like appearance, and yields in every possible direction. The object is not to obtain blood, which, indeed, I generally endeavour to avoid by bathing for a few minutes with cold water, if there be any disposition to bleeding, but to allow the cells of the cellular tissue to empty themselves of the fluid with which they are loaded, the effect of which is, that the skin, being further relieved of tension, is less likely to slough, and the tissue itself being no longer squeezed by the effused serum, the blood passes freely through its capillary vessels, and its life is preserved, instead of it becoming strangulated. If the tension be not sufficiently relieved, or if the disease be continued up the limb, it will be necessary to make additional cuts from day to day, which is the only chance we have, that I am aware of, to prevent the death of the cellular tissue, and it each time relieves the patient's sufferings most remarkably. In one instance of a man who had inflammation of the cellular tissue of the back of the hand, resulting from a strain, and which travelled up to the chest, I made about thirty cuts, mostly three inches in length each; during the course of the week, nearly the whole cellular tissue of the arm sloughed; but he completely recovered, his arm, however, closely resembling a piece of scored pork.

In these cases brandy, wine, porter, general good feeding, and humouring the appetite, are absolutely necessary, and infinitely preferable to medicine, which should be restricted to an opiate, or an occasional dose of castor oil, as needed.-J. F. S.]

91. In the treatment of the various kinds of erysipelas, we have given the treatment proper for each, and which has been proved by experience. The opinions, however, of the most distinguished physicians differ from each other in many important points on this subject. Thus the incisions should only be made in pseudo-erysipelas, and of the suitable length and depth, according to RUST, DUPUYTREN and LAWRENCE; while, according to HUTCHISON (a), they should be made early and in considerable numbers; but DOBSON (6) employs numerous punctures with a lancet in all kinds of erysipelas and on all parts of the body. In pseudo-erysipelas DUPUYTREN (c) professes, in some cases, to have effected a satisfactory resolution by blistering the diseased part: he, however, considers this remedy as doubtful, as in other cases he noticed deterioration and sloughs occurring after its use. But, in all cases of common erysipelas, if the tongue be moist and little red, the skin moderately hot, and slight general reaction connected with the local inflammation, he considers the suppuration produced by one or more blisters upon the inflamed part as the best mode of effecting resolution. Some (d) would arrest the extension by the application of a blister at the margin of the erysipelas; but others (e) entirely reject their use. BRETONNEAU (ƒ) and VELPEAU (g) have had the happiest results from moderate compression of a limb attacked with inflammation, even when the transition to suppuration seemed unavoidable and all other remedies had failed. LAWRENCE and DUNCAN have, on the contrary, observed bad effects resulting from this practice (h).

[Another mode of attempting to check the spread of erysipelas, is that of enclosing it, if small, within a space bounded by a belt, a quarter or half an inch wide, made on the skin with nitrate of silver; or, if a limb be affected, by gartering it in the same way

(a) Case of Erysipelas, with Remarks; in Med.Chir. Trans., vol. xiv. P. 213.

(b) On Treatment of Erysipelas by Punctures; in Med.-Chir. Trans., vol. xiv. p. 206.

(c) DUPUYTREN, as above, p. 322. OLIVET, Thèse, de l'Erysipèle Phlegmoneux, p. 30.

(d) ROCHE et SANSON, Nouveaux Elémens de Pathologie Medico-Chirurgicale, vol. i. p. 352. LAWRENCE, as above, p. 63.

(e) RAYER, Traité des Maladies de la Peau, p. 125. (f) Sur l'Utilité de la Compression dans les Inflammations Idiopathiques de la Peau. Par., 1815. (g) Mémoire sur l'emploi du Bandage Compressif dans le Traitement de l'Erysipèle Phlegmoneux, de la Brûlure et des plusieurs autres inflammations aiguës des membres; in Archives Générales de Médecine, Juin, 1826, p. 192.

(h) LAWRENCE, as above.

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.]