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LecturesON

MILITARY MEDICINE & SURGERY,Delivered at St. Mary’s Hospital,

BY JAMES BIRD, M.D., F.R.C.S.

LECTURE IV.

BURNS AND SCALDS.

Immoderate action of heat equally destructive of vitality as thatof cold ; injuries of the textures caused by the f01’mer, theirnature, di,erence, and division, according to seat and ex-tent; y’ frequency of burns from gunpowder amongst soldiers,and of scalds from steam amongst sailors; illustrations ofthese accidents in wafare, and the ratio of their occurrencein the navy; constitutional symptoms similar to those afterwounds; special plans which have been in vogue for the treat-M.6H< of such injuries; special indications to be followed incarrying out their scientific treatnient.

THOUGH the human body possesses surprising capability ofadapting itself to external circumstances, and of preserving itsequilibrium of heat amidst great variation of atmospheric tem-perature, yet it cannot long resist the injurious and destructiveimpressions of extremes of heat or cold, made through themedium of fluid or solid bodies. The irresistibly disorganizingeffect of cold, or caloric continuously abstracted from livinganimal textures, has been the subject of particular considerationin a preceding lecture; and we have now to turn our attentionto the opposite or reverse of this, where the too sudden orrapid radiation of caloric, from heated bodies, is followed bysevere inflammation, or direct death of the tissues. In otherwords, the inordinate action of either extreme heat or coldproves destructive of their vitality.

If the heat applied, though intense, be not long continued, apainful sensation of burning, followed by inflammation, is in-duced. The character of the inflammatoryprocess thus set up,is variable, just as the heat may have been applied in a solid orfluid form. When the former is the cause, generally the lifeof the tissue, from the more rapid radiation of the caloric, is inpart destroyed, and the cuticle and cutis are more or lesscharred. Should this effect be only partially produced, thecutaneous coverings adhere to, and are brought away with, theheated body, leaving a raw and very painful surface, whichsuppurates, and runs into troublesome ulceration. If the lattercause has been in operation, the surface of the cutis becomes theseat of inflammation, which terminates by serous effusion de-taching the cuticle in blisters. The inflammatory action pro-duced by the former is generally more severe than the other,and constitutes that which is more specially known in surgicallanguage as a burn, the latter being more familiarly termed ascald. But if all such accidents be indiscriminately namedburns, as is the general custom, they are usually divided, first,into those of a superficial kind, attended by mere redness, orvesication; and second, those deeper ones, where an eschar, orslough, has been produced by the greater conducting power ofth heated body applied. In the first kind, the epidermiccovering and true skin only are the seat of the injury, whichmay give rise to mere redness in the latter, or may producetrue inflammation, ending in vesication or suppuration. In thesecond kind, the vitality and organization of the derma areeither partially or wholly destroyed, often aggravated by thedeath of the subcutaneous and deeper-seated textures.Such are the two classes of burns, which commonly originate

from accidents in civil life, from the contact of boiling liquids,or the combustion of the patient’s clothing. But in accidentsof this kind, as they are met with in military life, and are pro-duced by explosions of gunpowder, the blowing up of tumbrils,the firing of mines, and the bursting of shells or fire-arms, athird division seems necessary, those complicated with contusedwounds and fractured bones. Sometimes, in burns producedby the exploding of unconfined gunpowder, the parts are

merely scorched and blistered, as when caused by boiling oil;but, for the most part, accidents of this kind are complicatedwith other injuries.

’

CASE.-In 1824, two men belonging to two troops of Indianhorse artillery, of which I was then assistant-surgeon, werethus severely scorched and otherwise injured, during the hurry

of a field parade at Poona. A nine-pounder horse-artillerypiece, that hung fire, by suddenly exploding the cartridge,which a gunner was in the act of ramming down, carried awaythe whole of his right hand and forearm close to the elbow,and otherwise scorched him severely. The other gunner, whohad only partially stopped the vent, and caused the accident,had his thumb and forefinger severely injured at the same time.The former had his arm amputated above the elbow-joint; andin the other case it was necessary to remove both thumb andfinger.CAsE.-Again in 1839, on the llth of March, I removed, at

Bombay, the right hand of a man, named Rowley, that had beenseverely scorched and injured by the bursting of a fowling-piece. At his admission into the European General Hospital,the skin of the palm of his hand was much blackened andblistered, and a wound of six inches in length extended, in anoblique direction, from the first joint of the thumb to the outeredge of the ulnar joint, which had been laid open. Several ofthe carpal bones having been fractured, and there being littleprospect of saving the hand without risk of gangrene, futureexfoliation, and lock-jaw, amputation was recommended, butthe patient refused to submit to the operation. During thenight, however, having suffered from intense pain, he requestedto have the hand removed at the wrist. I accordingly per-formed the flap operation for mdio-carpal disarticulation atthe wrist; the larger flap having been made from the back ofthe hand, and the smaller from its palmar aspect, in themanner recommended, in 1815, by M. Gouraud, and othermilitary surgeons. Three arteries required ligature, and theflaps were simply brought together by adhesive straps, andcovered with cold-water dressing. The radial side healed bythe first intention; but on the ulnar edge the stump becameirritable, yielded a copious purulent discharge, and ultimatelyhealed by granulation. The patient was discharged, well, onthe 8th of ApriL On examining the parts after removal, thecarpal bones were found to be fractured and dislocated, themetacarpal bone of the thumb splintered longitudinally, andthe ulnar part of the wrist laid open.The appearances observed in those burns caused by the rapid

and temporary contact of flame, from sudden explosions ofloose gunpowder, are often the same, as already said, whenthey originate from boiling liquids. In the ships employedagainst the batteries at Sebastopol, many men were scaldedfrom the explosion of shells. When shells accidentally strikeand explode powder magazines, or the tumbrils of artillerywagons, such kinds of accident are frequent. On one occasion,during the siege of Sebastopol, a French tumbril of gunpowderwas exploded by a Russian shell, causing these and othersevere injuries amongst several of the soldiers. In the Sutlejcampaign, a similar accident occurred from carelessness. Whilethe French attacks against the Malakhoff and little Redan weregoing on, a powder magazine suddenly exploded in the leftcurtain of the Malakhoff, just between it and the little Redan.Many men were scorched by the explosion; others woundedby the falling timber and stones; and, worse than all, a panicwas created in front of the assaulting columns. On shipboard,again, scalds are frequently caused by the contact of boilingfluids or steam. In the Royal Navy, on the East India station,the ratio of these accidents, from 1837 to 1843, was 2’8 per1000 of mean strength.Such are the local phenomena which usually attend burns

and scalds. When limited in extent, or confined to the lowerextremities, and least sensitive parts of the body, they are notaccompanied by either shock or constitutional symptoms of re-action ; which, in the severer forms of such injuries, imperilthe patient’s life. In extensive explosions of gunpowder, thelocal phenomena of the scorched skin are sometimes of a verygrave character. The surface generally is deeply blackened,and numerous grains of gunpowder are found imbedded in theskin, where, when allowed to remain during the cure, theycommunicate an indelible bluish-white colour to the new cover-ing of the injured part, similar to the marks of anchors andother figures to be seen on the arms of sailors. Stromeyer, inhis Maxims," mentions two severe cases of this kind, whichhe had to treat after the battle near Idstedt. Two artillerymenhad their bodies extensively burnt and blackened there, by anexplosion of gunpowder, while their comrade was found deadon the spot. Though their skins presented a hideous aspect,and one of them had meningitis, requiring ice to the head andcalomel internally, yet both ultimately recovered their health,after no great lapse of time : from which circumstance he isdisposed to consider that such class injuries are less dangerousthan when produced by boiling fluids. But when the patient’sclothing has been set on fire, and the injury to the skin is not

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superficial, but has penetrated deeper into the subjacent tissues, and pain of the affected tissues, and thus keeping in check thethe danger of the accident must be not only estimated by its violence of inflammation and its consequences. Sir Jamesdepth and extent, but by its situation, the age and constitution Earle’s plan of treating extensive burns by means of cold waterof the patient. or ice is also reducible to this last category.The constitutional symptoms which result from severe burns, The local treatment of burns, conducted in due regard to,

are quite of as serious a character as those attendant on severe general principles, may be either stimulating, or cooling andwounds, though somewhat different in regard to the special in- sedative, in its nature. Should a preference be felt for either,Rammatory affections of the internal mucous and serous linings the particular plan of treatment must be always adapted toof the great cavities of the chest and abdomen that follow the peculiar circumstances and stage of the injury. While thethem. Their severity is essentially dependent on the depth parts were yet in a state of inflammatory redness and pain,and situation of the burn, as well as the age and constitution of short of vesication, Ambrose Pare, and other military surgeonsthe patient. These constitutional disturbances consist of, first, of bygone days, were wont to apply poultices of bruised onions,a shock, or depression and collapse of the nervous system, ac- with the view of allaying pain and preventing vesication, andcompanied by a quick, feeble pulse, pallor and coldness of the always with the best possible effect. He particularly mentionsextremities, or by violent and repeated shiverings, and some- the case of a German of Montegan, whose face and othertimes coma; indicatory of a considerable amount of internal portions of the body were grievously burnt by the explosion ofcongestion, as revealed by pathological anatomy in cases of his powder-flask while on guard. Pare applied the poundeddeath. These symptoms, as in wounds, usually present them- onions to the middle of the face, and made use of otherselves during the first twenty-four hours. The second series of medicines, commonly applied for burns, to the other part&bgr;symptoms, which commence on the second day, and may ex- At the second dressing, he observed that the parts dressed withtend to the second week, mark the period of febrile reaction and onions were quite free from blisters and excoriations, the otherinflammation. These are not materially different from those parts being affected by both. Though I have no personal ex-already described, and found in connexion with other traumatic perience of the efficacy of this remedy in burns, as used byinflammations. From the extensive anatomical sympathy ex- Pare, and some others of the older surgeons, I have observedisting between the external surface of the skin and the internal the almost instantaneous relief it gives from pain and swellingmucous lining of the bronchise and abdominal viscera, the simi- in cases of persons stung by wasps and bees; and have littlelarity of their exhalent and respiratory functions, symptoms of doubt but that it will be found equally efficacious for the classbronchitis and pneumonia, or abdominal muco-enteritis, set in of injuries now under consideration, provided we have recourseat the same time. When these affections end fatally, both to it before vesication or abrasion of the skin has taken place.pleuritic effusion into the chest and follicular ulceration of the A rather extensive experience of the almost invariable goodinternal mucous membrane, have been usually met with on effect of finely carded cotton applied to the scorched parts, asdissection. The third stage is one of cachohymia and hectic: already noticed, urges me to a strong recommendation of thiswhere the long continuance of exhausting suppurative dis- remedy on all occasions, where we have yet the opportunity ofcharge from the skin, may so weaken the general powers of preventing vesication, or of converting the vesicated surfacenutrition, that a suppurative diathesis is engendered and fol- into the healing process of scabbing.lowed by all its fatal consequences. The symptoms which ac- In the first class of burns, where vesication had not yetcompany this stage, occur from the end of the second week to taken place, the same indications of treatment for procuringthe termination of the case, and frequently prove fatal by the the resolution of increased vascular action was fulfilled bylungs and pleurae being generally more implicated in the morbid Heister, in the repeated application to the parts of oil ofresult than are the abdominal organs. Burnt parts are usually turpentine. Dr. Kentish’s plan of treating burns by thismuch disposed to run into troublesome ulcerations, and produce remedy, mixed with resinous ointment, was only the extensionlarge flabby granulations, which rise above the surrounding of a practice long before employed. A modification of thisskin; a contingency more frequently met with in military than method, where two parts of the linimentum aq. calcis arein civil life, as all the debilitating influences of privation, mixed with one-third oil of turpentine, and applied by meansfatigue, atmospheric humidity, and anew climate, are there in of lint, has been often used by myself with great advantage,action to aggravate such injuries quite as much as other kinds and found equally applicable to the two first classes of burns,of wounds. without or with vesication, as well as in those where the

y’gatme. &mdash;No class of surgical injuries has been more the tissues are superficially charred, and eschars formed. Thesubject of varied and even opposite modes of treatment than good effects of all the remedies just noticed follow, probably,have burns. From the frequency of such accidents amongst as the result of their stimulating and soothing influence on theparticular classes of workmen, they have been frequently aban- external surface, and of the constitutional reaction induced.doned to the empirical knowledge of those most interested n It is always useful to lull, as far as possible, after each dressing,affording the sufferers relief, and restoring them to their former the pain and irritation produced in cases of severe burns. Some

employment, but without those who administered knowing French practitioners therefore employ, with advantage, medi-anything beyond the usually good practical effect of the re- cated tepid baths, prepared with decoction of mallow or linseed,medies. Two of such special methods of cure, the application and the addition of a moderate quantity of the extract ofof vinegar, and the use of Carron oil (lin. aq. calcis), obtained belladonna or henbane. Beaupre mentions that he thus savedat one time very general and desfrved celebrity, and are still two sailors, who, at a water fete given to Prince Eugene, bypermitted to hold their place as acknovledged beneficial means the town of Ancona, had their whole bodies horribly burnt,for the treatment of burns. The action of vinegar on the skin from the explosion of a barrel of gunpowder. A third victimcreates redness, therefore stimulates, and may be employed be- to the same accident, but who did not use the tepid sedativefore vesication has commenced, or in cases where there are bath, under the treatment of another surgeon, miserablyeschars; being a plan of treatment introduced amongst his perished.workmen by Mr. Cleghorn, a brewer of Edinburgh ; the other In the less extensive and formidable form of scalds and burns,was the application generally made use of by those employed where no great amount of collapse or constitutional depressionat the Carron Iron Works in Scotland, and who were suffering is present, the employment of cold water or ice to the part isfrom injuries of this nature. One other special method of the followed by immediate and most decisive relief. If applied atsame kind, which is certainly of great efficacy, is to envelope a sufficiently early period, this method is capable of obviating.the parts in cotton, and support them with a bandage. In this vesication, and will always allay exalted sensibility, and mode-way, air being thoroughly excluded from the cutaneous surface, rate inflammation. In spite of the objections brought against.the erythematous vascularity of the skin is allowed to subside this practice by the distinguished and experienced Baronby resolution, or to heal up by scabbing, when the tissues are Larrey, the great utility of it cannot be doubted, if judiciously-either abraded or superficially destroyed. This mode has been employed, and always with due regard to the absence ofused from time immemorial by the natives of India, though a symptoms manifesting states of internal congestion and consti-similar method was long since known in the cotton districts of tutional depression. Both Sir George Ballingall and StromeyerAmerica, and seems to have been from thence introduced into have expressed very decided opinions of the remedial advan-English medical practice. With a clearer appreciation now of tages we derive from cold in such class diseases.the therapeutic action of these several remedies, we are enabled Cold so employed is a means of partly fulfilling the indica-to reduce the locally good effects of all to two general principles tions of the second local plan of treating scalds aud burns, byof treatment-first, in preventing and moderating the deve- refrigerants and sedatives.’ Whenever portions of the trunklopment of inflammatory action in the weakened capillaries by are much involved in the injury, and manifestations of pul-moderate additional stimulation, pressure, and exclusion of air monary disease become apparent, the employment of cold musttill the parts resume their normal action, or heal up under the I of course prove highly unfavourable to the patient ; and, underscabbing process; or second, by soothing the nervous irritation such circumstances, warm sedative applications must be used

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in.place of cold ones. The French medicated tepid bath beforementioned, which is both emollient and sedative, seems par-ticularly well suited to the conditions of such complicated casesof disease. The chance of a successful result will here, too,depend on the judicious employment of constitutional means,particularly those saline eliminating diuretics and purgatives,capable of establishing a vicarious action, while the cutaneousfunction is in a great measure impeded.

If the skin and other tissues have been much destroyed bythe heat, they must necessarily go through the tedious and ex-hausting process of sloughing and suppuration. The proclivityof the case, however, to troublesome degrees of either, willdepend in a great measure on the extent of parts destroyed,and on the suitable nature of the treatment adopted, formoderating, by both local and general means, the violence of.reaction. When suppurative action has been fairly established,the mode of treatment necessary is not in any respect differentfrom that of like granulating sores, attended by partial sloughsand copious discharge. The patient’s strength must be keptup by quinine and generous diet, and the dressings should benow of such a kind as are calculated to restrain purulent dis-charge and promote cicatrization. The various preparations ofzinc are well adapted to fulfil these intentions; and if thegranulations are large and flabby, the sore may be advan-tageously washed twice daily with a solution of sulphate of,zinc three or five grains to an ounce of water, and afterwardscovered with an ointment containing some of the oxides of thismetal. Mr. Coulson has lately treated successfully, in St.Mary’s Hospital, several cases of burns by an application ofcastor oil and white oxide of zinc. During the process of cica-trization we must endeavour, by means of proper bandagingand position of the parts, to prevent, as much as possible, anyunnatural adhesions of the affected tissues, and to counteractany deformity that threatens from the contraction and hyper-trophy of the cicatrix. Sometimes the local injury may be soextensive or complicated as to render amputation necessary,instances of whch have been already given.But while due attention must be given to the local treatment,

constitutional remedies are of great importance in renderingeffectual the former. During the stage of depression the patientmay die, in a state of hopeless collapse, from the severity ofpain and extent of the injury, just as from the shock of gun-shot wounds. Thirty minims of the tincture of opium, with adrachm of nitrous ether, in some warm brandy-and-water,should be given; and whoever has witnessed the instantaneousand almost miraculous effects of opium in stopping the shiver-ing of an intermittent fever will be at no loss to understand itsefficacy in bringing on reaction after severe burns. This beingonce established, the surgeon’s first attention must be directedto moderate its violence by means of saline eliminants, chieflythe salts of potash in solution, combined with diaphoretics andantimonials. The bowels must at the same time be kept open’by some mild laxative; or in cases where the patient cannot Ibe moved without great pain from his position, glysters insteadof laxatives may be preferable. General bleeding may occa-sionally be necessary. The diet of the patient must at thesame time be of the most mild and demulcent nature, and mayconsist of arrowroot, beef-tea, or sago, given according to cir-cumstances.

CONTRIBUTIONS TO PRACTICAL SURGERY.

BY JOHN ERICHSEN, ESQ.,PROFESSOR OF SURGERY AT UNIVERSITY COLLEGE, AND SURGEON TO

THE HOSPITAL.

II.ON TOPICAL MEDICATION OF THE LARYNX.

THE practice of treating chronic disease of the larynx by thelocal application of a strong solution of the nitrate of silver isby no means of very recent origin. Many years ago it wasemployed in this country by Sir C. Bell; and Dr. Watson, inhis " Lectures," speaks of the practice as having been exten-sively had recourse to by Mr. Vance, who, being a naval sur-geon, applied to it the very expressive term of "swabbing." "So far back as 1818, M. Trousseau states that " his preceptor,"M. Brettonneau, used the saturated solution of the nitrate ofsilver as a local application in diseases of the larynx, applyingit by means of a sponge attached to a piece of whalebone. Ofate years this practice has become a very favourite mode ofreatment in many diseases of the throat, and in not a few ofhe lungs, and has been brought very prominently before the

profession, chiefly through the writings of Trcusseau, in Paris,and of Dr. Horace Green, in New York.Of the great value of the local application of a strong solu-

tion of the nitrate of silver to the throat in many affections ofthe larynx there can be no doubt. Indeed, I believe it to beimpossible to bring deeply-seated and very chronic inflam-matory or ulcerative affections of this part of the air-passagesto an equally satisfactory termination by any other means, or,indeed, to cure the majority of them without this " topicalmedication;" and the profession is undoubtedly under a debtof gratitude to those practitioners whose names I have men-tioned, through whose example and writings the utility of thismethod of treatment has been demonstrated.

During the last few years an attempt has been made to treatdiseases of the respiratory organs seated below the larynx bythis method; and by passing a sponge-tipped probang betweenand beyond the vocal cords to apply a solution of the nitrateof silver, and various other medicaments, to the interior of thetrachea, the bronchi, and even into tuberculous cavities of thelungs. In my recent work, " The Science and Art of Sur-gery," whilst discussing this subject, I ventured to express mydoubts whether this practice, though commonly spoken of andprofessedly employed, had ever in reality been carried out;and I proceeded to state that I had no hesitation in expressingmy conviction that the sponge probang had never in the livingsubject been passed beyond the true vocal cords, though I be-lieved that with the requisite dexterity it might be got betweenthe lips of the glottis, and the solution freely applied to thoseparts; and I proceeded to say, that, in my opinion, in thosecases in which the sponge has been supposed to have been passedbeyond and between the true vocal cords, and in which theoperator speaks of having felt the constriction exercised bythem in its entry and exit, it had not entered the larynx at all zbut had passed behind this tube into the oesophagus; the feel-ing of constriction being produced by its passage beyond thethyroid and cricoid cartilages where they project backwards,and that the caustic solution had been applied, not to the in-terior of the larynx, except when a few drops accidentallysqueezed out by the pressure of the sponge against the lips ofthe glottis have been inhaled, but to those extensive folds andplanes of mucous membrane which invest the base of the epi-glottis, and the back of the thyroid cartilage, and which, withtheir subjacent cellular tissue, are usually greatly congested,and infiltrated in chronic throat diseases;-in fact, that thesponge probang is passed in the way represented in the annexedwoodcut. ,

Indeed, were it otherwise, and did the sponge reallypenetrate between and beyond the true vocal cords into thetrachea, hitching against these, as it was withdrawn, with ajerk, or a distinct feeling of constriction, this operation wouldbe one of the most dangerous in surgery, the whole safety ofthe patient depending, not on the dexterity of the surgeon,but upon the integrity of the thread corroded by nitrate ofsilver with which the sponge is attached to the whalebone:did that give way, the sponge, hitching against the vocal cords,must necessarily be detached ; and what would the condition ofthat patient be into the chink of whose larynx half a cubic inchof sponge was impacted, or in whose trachea such amass, satu-rated with nitrate of silver, lay loose ?

This opinion, to which I still adhere, was deliberately formedand based on experiments on living animals, and on the deadsubject, on observations made in cases of cut throat, and on afair share of practical experience in the treatment of the diseasesof the air-passages, not only in ordinary hospital and privatepractice, but when acting as surgeon to the City of LondonHospital for Diseases of the Chest. It has, however, met with