summer sun.

flammatory condition produced by exposure to a temperature somewhat below the boiling point of water, and consists of a diffused redness and slight swelling, accompanied with a hot, smarting, itching sensation. We often see this degree in the bather exposed to the hot rays of the The anatomical effect is an immediate hyperemia of the smaller cutaneous vessels, followed by paresis and passive congestion. The second degree, or combustio bullosa, includes that form in which blistering takes place. Here there is an exudation of serous fluid into the tissues, particularly the rete malpighii, and a portion of the epidermal layer is lifted up, forming the covering of the blister. The blisters may develop immediately or several hours after the accident has occurred. There is often marked pain, and, if the burn is at all extensive, high fever may result.

The third degree, or combustio escharotica. The characteristic point for burns of this degree is eschar formation-the immediate mortification of the skin. Albuminous coagulation occurs, affecting the contents of the vessels and the serous fluid and albuminous substance of the tissues; greater or less areas are deprived of nourishment, and necrosis of tissue follows. On the other hand, actual carbonization may occur at once.

The pain of a burn may be of every grade, from moderate burning to intense agony. The most painful variety is that in which the outer layers of the skin are destroyed, exposing the nerve endings, while very little pain is usually complained of when total destruction of the skin has taken place.

These local symptoms or anatomical changes I have mentioned do not complete the full picture of a burn. Many grave complications affecting the body as a whole are often associated. These constitutional symptoms may vary from slight fever in burns of the first degree to profound shock in the severer forms, followed by reaction, and this succeeded by congestion or inflammation of the viscera. For example, let us take an average case, that of a person whose clothing has been ignited. We will perhaps find the greater portion of the injury of the first and second degree, only limited areas presenting the third degree. During and immediately after the accident the patient is very much excited, often acting insanely, screaming and moaning; but becomes quiet after the injuries are properly dressed, and bears the suffering comparatively well, with perhaps only faint groans and whines. Otherwise is perfectly rational and will tell you all about how the accident occurred. As a rule, no urine has been passed since, and catheterization is sometimes negative. In about five or six hours an apathetic state supervenes with yawning and deep sighs, often with deep inspirations and hiccough and then vomiting. Rapidly following this there is marked restlessness, confusion, clonic convulsions, and finally absolute insensibility. Noisy delirium gives place to a comatose state or the coma immediately follows

the former apathy. The respirations are rapid and shallow, the pulse. frequent and irregular, and within twenty-four or forty-eight hours death. ensues, either in the midst of the noisy delirium or during the comatose condition. These symptoms may be prolonged, or even delayed, for several days, and then come on in rapid succession.

The question naturally arises, what is the cause of death? The generally-accepted theory now is nervous shock, and it undoubtedly plays the greatest part. If the patient survives the first stage, and time is allowed for inflammatory reaction to set in before the tatal symptoms appear, then it would seem that death was due to the general intoxication. Even if the injury was not of sufficient magnitude to cause the above train of symptoms, death may occur later on from an intercurrent, pneumonia, Bright's, erysipelas, pyemia, etc., or from exhaustion. Therefore, what can we say in regard to prognosis?

In the first place it certainly must depend upon the intensity and extent of the local lesion. In burns of the first and second degree it is generally favorable, but is always somewhat doubtful if the latter is extensive or affects a delicate individual. Those of the third degree are always of serious importance. It has been noticed that in the adult, if more than two-thirds of the surface is involved in a burn of the first degree, life is usually destroyed, while if one-third of the surface is burned to the second or third degree, death will almost inevitably result. Many and varied have been the methods of treatment suggested and advised for these injuries; from the cook's dredger to complicated germicide mixtures, the underlying principle has been the same, namely, to prevent mechanical irritation of the surface of a hypersensitive wound and allow granulation to go on unhampered. The commonest and most dangerous source of irritation to a burn is infection. For a long time suppuration was considered inevitable, and very little was done to prevent it. The surgeon should bear in mind the necessity of early aseptic and antiseptic measures. A burn is a wound and demands as careful attention as any other surgical condition. The earlier a burn can be dressed the better will be the result.

Our attention should first be directed to the alleviation of the pain. In burns of the first degree this may best be accomplished by dusting the parts with some alkaline powder or by lead water compresses, collodion, etc. This is about all that is needed. When the burn is of the second or third degree, it becomes a more serious proposition. Of the household remedies it is sufficient to say that they should not be used. Friends would do best by the patient and assist the surgeon if they would confine their efforts to carefully cutting away whatever clothing was loose about the burn, wrapping a piece of oiled or wax paper, such as florists use, around the wound and leave it alone. Upon removing the oiled paper protective, with scissors and forceps cut away all shreds of burned clothing remaining. Sterile puncture of the blisters at their

most dependent parts relieves the sensation of tension, but wherever possible the covering of the blister should be preserved. With care cut away the greater part of the charred subcutaneous tissue, an anæsthetic being sometimes allowable if it does not increase shock. All of the burned tissue will not be removed at one dressing, inflammation assists in the removal.

In selecting an application for a burn, two principles are involved; the agent must cause no irritation and must be antiseptic. Having cleaned the surrounding skin, irrigate it with a 1-1000 bichloride or a 3 per cent. carbolic solution, and syringe the surface of the burn with hydrogen peroxide (one part to six of water). The danger from the use of poisonous antiseptics should ever be borne in mind. When the burn is at all extensive, one of the best protective dressings is rubber tissue in strips about one-quarter to one-half inch wide, these applied all over its surface and well over the edges to sound skin; then fluffed sterile gauze and bandage. When granulation is well under way, skin-grafting after Thiersch's method may be used.

Would like to call especial attention to the water bath of Hebra for extensive burns. All the trouble to the attendants and the pain of changing dressings is done away with. Cleanliness is promoted and healing favored. The patient lies and moves at will. It is not as practical perhaps as other methods, but in burns covering a large surface it is certainly worthy of consideration.

For burns of limited extent a protective dressing, such as carron qil, olive oil, white of an egg, ichthyol (2 per cent.), resorcin, etc., on pieces of gauze will be found of service.

Picric acid in various solutions has been advised as an early treatment for burns before granulation commences; it is said to deaden painFor some time past I have been very partial to a combination of alum 15 per cent., (non-irritating), carbolic acid 2 per cent., and ichthyol 5 per cent., in a petrolatum base. It is one of the best dressings for burns of any degree that I have ever used, and when considering the splendid results I have had with it, I feel free to recommend it most earnestly.

Many kinds of dressings have been advocated, but no matter what the dressing is, do not change frequently unless special indications exist demanding it; the less often the better.

I am opposed to dusting powders of all kinds, when the burn is beyond the first degree, because they are as foreign bodies to a burn, and prove their irritant properties by the amount of discharge they cause. Secure protection for the granulations forming over a burned area, and we will obtain a perfectly-healed wound with no danger of distortion of the scar or loss of function from contraction.

The constitutional treatment consists of supporting measures pain-relievers.

and

DISCUSSION.

DR. BLITZ: Dr. Turner Anderson recommends the use of flour. The best results I have obtained were from the use of picric acid, two to five per cent. No scar. I believe the danger is within about forty-eight hours after the injury. Here it is due to pneumonia, if the kidneys act normally. By excluding air, the pain is relieved.

DR. SIMRALL ANDERSON: The main consideration is to exclude air. I saw a patient treated recently by keeping in water bath and there was no pain after treatment was begun. I have never seen a burn which didn't result in pus formation. I like an ointment of alum, carbolic acid, and ichthyol for local use. I have not gotten good results from the use of picric acid.

DR. RUSSMAN: I don't agree with the essayist in cutting tissue. I use a combination of alum, carbolic acid, and ichthyol. in eight hours.

away the charred Change dressing

DR. BARNETT: I have used every dressing that I have ever heard of, but prefer the following: Ichthyol, starch, lime water, and oxide of zinc. Where the pain is severe I use orthoform and vaseline, for two or three days and then the other combination.

DR. HOFFMAN: I have gotten best results with picric acid. Have seen cases given an anesthetic, the surface scrubbed with green soap and then treated as simple wound.

DR. MEYERS: I think it is bad surgery to clean any burn. Dr. A. M. Vance advises never to clean them unless they contain sawdust. By scrubbing a burn we remove the clots, which have formed, and thus infection can result from absorbtion.

DR. LEO BLOCK: I use picric acid, sat. solution on cotton. By closely watching the kidneys, uremia may be avoided.

DR. BIZOT: A burn is a severe condition. Treat as in any other condition of shock. Morphine hypodermatically. Let nature remove the necrotic tissue. I treated case of a man, burned from the nipple line up. One ear burned off, one eye out. Kept carbolic and saline solution irrigations constantly applied. This man recovered.

DR. RICHARDSON: The question of prognosis is very important, a burn at first appearing simple often becoming serious. My results with picric acid have not been good, pain, severe and constant, being complained of.

DR. VAN ZANDT (closing): I wish to thank you for the thorough discussion. Use morphine if exclusion of air does not relieve the pain. I have gotten excellent results from the use of the combination of alum, carbolic acid, and ichthyol. I used this on a severe burn of the palm of hand, changing the dressing every half hour for five hours, with very happy results. I have had no good results with picric acid. I don't believe in scrubbing. Danger from antiseptic solutions is from absorbtion. Don't change dressings too frequently.

AS

HERNIA, ITS COMPLICATIONS AND TREATMENT.

BY L. G. BOWERS, M. D., RICHMOND, IND.

S indicated by the title, this paper covers only the complications of hernia and the treatment of these. The most frequent complications of hernia may be divided into irreducibility, inflammation, obstruction, and strangulation, followed by gangrene.

* Read at Louisville Medical College Alumni Association Meeting, April —, 1905.

An irreducible hernia is one whose contents cannot be reduced or returned into the abdomen. This term irreducibility is only a comparative one, for a hernia may be irreducible at one time and reducible at another; or, again, a part of the contents of the sac may be irreducible and part reducible.

In an irreducible hernia there is no inflammation, strangulation, nor interference with the blood supply, or, we might say, no abnormal condition, except that it cannot be reduced.

The variety of hernias which are most commonly found in this class are: First, the femoral; second, umbilical; and last, the inguinal. It behooves us to give more consideration to an irreducible femoral hernia than we would to an umbilical or inguinal, because there are about twice as many femoral hernias which are not reducible as umbilical, and five times as many umbilical as inguinal.

sac.

The cause of irreducibility of a hernia may be merely the contraction of the tissue through which the neck of the sac passes, preventing the contents above from being returned; or, again, it may be due to external pressure, which will lead to atrophy of that part of the contents which occupies the neck of the sac. Another very frequent cause is the thickening and contraction of the peritoneum forming the neck of In acute cases there may be an hour-glass contraction occurring at the superficial ring. And one of the most frequent causes is increase of the bulk of the contents of the hernia sac after they have passed out. Such thickening is most commonly in the omentum. That is, there is a tendency to the deposition of fatty tissue in its contents, and the size will consequently become greater. Or we may have a development of fibrous tissue, the outcome of chronic congestion. Adhesions may form, and

thus prevent return, and it then becomes an inflamed hernia.

In all hernias in which the contents of the sac are irreducible, omentum is usually its chief component. After this we are most likely to

find large intestine and then small intestine.

An inflamed hernia may merely be a local peritonitis when it is the sac wall which is chiefly inflamed, or the contents of sac may also be involved in the inflammation. The inflammation may be caused by external injury, by the improper fitting of a truss, or where a truss had been applied without reduction. One of the chief causes is a too severe attempt at taxis in trying to reduce the sac's contents. It is always a matter of regret, upon being called to see a patient, to find that he has become very tender and really bruised by too prolonged effort at taxis. It is not an uncommon thing for the doctor to say, "I did my very best to reduce this hernia and have failed. I have worked hard for an hour or two on it without success." We can nearly always be safe in predicting that upon opening the sac a dark gut with adhesions will present itself. I believe that if we could see the results following these extreme efforts at taxis a few times, we would desist sooner than we do. If an adult pa