ness of the conjunctiva. Watch the pulse, and if it flags at once suspend the administration.

Local Anesthesia.-Freezing with Ice and Salt.— Take one-quarter of a pound of ice, wrap it in a towel, and break it into fine bits; add one-eighth of a pound of salt; then place the mixture in a gauze bag and lay it upon the part. The surface becomes pallid and numb, and in about fifteen minutes is decidedly analgesic. A spray of rhigolene freezes in about ten seconds. It is highly inflammable. Chlorid of ethyl comes in glass tubes. Remove the cap from the tip of the tube and hold the bulb in the palm: the warmth of the hand causes the fluid to spray out. Hold the tube some little distance from the part and let the fine spray strike the surface. The skin blanches and whitens, and is ready for the operation in about thirty seconds. Ether-spray anesthesia was suggested by Benjamin Ward Richardson.

Cocain Hydrochlorate.-Always bear in mind that cocain is sometimes a decidedly dangerous agent. There are on record fourteen deaths from cocain (Reclus). Never use over two-thirds of a grain upon a mucous surface, and never inject hypodermatically more than one-third of a grain. The urethra is a particularly dangerous region, and so is the face. Mild cases of cocain-poisoning are characterized by great tremor, restlessness, pallor, dry mouth, talkativeness, and weak pulse. In severe cases there is syncope or delirium. Death may arise from paralysis or from fixation of the respiratory muscles (Mosso). Cases with a tendency to respiratory failure require the hypodermatic injection of strychnin. In cases with tetanic rigidity of muscles give enemata of chloral, hypodermatic injections of nitroglycerin, or inhalations of the nitrite of amyl. In cases marked by delirium, if the circulation is good, give chloral or hyoscin. In any case give stimulants, employ a catheter, and favor diuresis. Cocain-poisoning is always followed by a wakeful night. Cocain should not be used if the kidneys are inefficient. In using cocain try to prevent poisoning. Have the patient recumbent. One minute before giving the cocain administer one drop of a 1 per cent. alcoholic solution of trinitrin, repeating the dose once or twice during the operation. In operation on a finger, after making the part anemic tie a tube around the root of the digit before injecting cocain, and after the operation gradually loosen the tube. A hot solution of cocain is more efficient than a cold solution (T. Costa); hence hot solutions can be used in much less strength and are safer. Merck prepares a safer agent

than the hydrochlorate, and that is, the phenate of cocain. This is a honey-like material, soluble in alcohol. It is used locally in from 5 to 10 per cent. solutions. It takes longer to act than does the hydrochlorate, and it coagulates the tissue-albumin, and thus absorption is lessened. It causes anemia and anesthesia, and retards germ-growth (Kyle). Glück and Bartholow some time ago advised a mixture composed of cocain hydrochlorate and carbolic acid.

Eucain hydrochlorate is far safer than cocain, and in most cases is to be preferred to it. It is used in the strength of from 2 to 5 per cent. It can be boiled without destroying its properties, and hence can be readily rendered sterile. Unfortunately, it occasionally happens that the injection of eucain causes sloughing, especially at the extremities, in fatty tissue, in tendon-sheaths, and in bursæ.

Infiltration-anesthesia was devised by Schleich of Leipsic, who was dissatisfied with cocain, because it is not safe and sometimes fails to produce satisfactory anesthesia owing to want of thorough diffusion. He found that salt solution (per cent.), if injected into uninflamed parts, produced anesthesia. To obtain this anesthesia the part must be distended by wide infiltration. If minute quantities of cocain, morphin, and carbolic acid are added to the solution, the anesthesia becomes more thorough and more prolonged, and can be obtained even in inflamed areas.

Schleich uses three solutions:

No. 1, a strong solution, which is used in inflamed areas: cocain hydrochlorate, 0.20 gm.; morphin hydrochlorate, 0.025 gm.; sodium chlorid, 0.20 gm.; distilled water, 100 gm.; phenol (5 per cent.), 2 drops.

No. 2, a medium solution, which is employed in most cases cocain hydrochlorate, 0.10 gm.; morphin hydrochlorate, 0.025 gm.; sodium chlorid, 0.20 gm.; distilled water, 100 gm.; phenol (5 per cent.), 2 drops.

No. 3 is used for extensive operations: cocain hydrochlorate, 0.01 gm.; morphin hydrochlorate, 0.005 gm.; sodium chlorid, 0.20 gm.; distilled water, 100 gm.; phenol (5) per cent.), 2 drops.

The injections are begun in the skin, not under it (Fig. 253), and are made one after another until the area to be operated upon is surrounded above, below, and on all sides with Schleich's solution. This infiltration can be made painlessly by touching with pure carbolic acid the point where the needle is to be inserted, or by freezing this area with ethyl chlorid. When deeper tissues are reached they are infiltrated

before incising them. If a nerve comes in sight, touch it with a drop of pure carbolic acid (Lund). Schleich's fluid is more efficient when cold. Van Hook says that the anesthesia obtained by this method is due to artificial ischemia, pressure

upon the tissues, the direct action of the drugs, and the lowered temperature. The method is very efficient and can be used for operations of considerable magnitude.

XXX. BURNS AND SCALDS.

Burns and scalds are injuries due to the action of caloric. Scalds are due to heated fluids or vapors. There is no true pathological difference between burns and scalds. Dupuytren classifies burns into six degrees, as follows: (1) characterized by erythema; (2) characterized by dermatitis with the formation of vesicles; (3) characterized by partial destruction of the skin, which structure is not, however, entirely burnt through; (4) characterized by destruction of the skin to the subcutaneous tissue; (5) characterized by destruction of all superficial structures and of part of the muscular layer; (6) characterized by "carbonization" of the whole thickness of the muscles.

The symptoms are local and constitutional. Local symptoms are pain and inflammation, which vary in nature, in intensity, or in degree according to the extent of tissuedamage. Constitutional symptoms are shock, followed by a severe reactionary fever, with a strong tendency to congestion of internal parts. The constitutional symptoms which follow a severe burn are due in part to the absorption of toxic materials from the seat of injury, these materials hav

1 Lund, Boston Med. and Surg. Jour., Feb. 6, 1896.

2 Med. News, Nov. 16, 1895.

ing been formed by the action of heat on the body-cells and fluids. Sepsis is not infrequent. The stages are often designated as prostration, reaction, and suppuration. Death may be due to shock, to sepsis, to exhaustion, to congestion of the brain, lungs, or kidneys, or to Curling's ulcer of the duodenum.

Treatment. The local treatment of slight burns (as sunburn) is to moisten the parts frequently with a saturated solution of bicarbonate of sodium, a solution of citrate of lime, or a 18 solution of phénol sodique. In burns of moderate degree a mixture of zinc ointment with iodoform, though not antiseptic, is a comfortable dressing. The author has been using normal salt solution for a number of years, and likes it very much. Some surgeons use a saturated solution of picric acid. Carron oil consists of equal parts of linseed oil and lime-water. It allays the pain of a burn, but it is a filthy preparation, and its use is followed by much pus-formation. Cosmolin gives comfort as a dressing, but should not be used on the face, lest it cause pigmentation. The elder Gross used lead paint. A solution of nitrate of potassium allays the pain. In a severe burn cut away the clothing, avoid exposure to cold, wash the part with a solution of peroxid of hydrogen and then with a warm solution of boric acid, open the vesicles with an aseptic needle, dust. with iodoform, and dress with aseptic cotton, or else dress with lint soaked in salt solution. Aseptic dressing of a burn is often painful, and may demand the use of an anesthetic. Change the dressings no oftener than is required, and at each change wash the burn with peroxid of hydrogen and boric acid, take away sloughs, and reapply iodoform and cotton or salt solution. Where extensive destruction of tissue has taken place use splints and extension to limit contractures, and skin-graft as soon as possible. If granulation is slow, stimulate with copper-sulphate or mild silver-nitrate solutions. Exuberant granulations require burning down. Flabby granulations require pressure. If healing is slow, or if the burn is extensive, skin graft. When an extremity has been carbonized amputation must be performed. In constitutional treatment bring about reaction; combat pain with opium; and keep the bowels and kidneys active. If suppuration occurs, give tonics, stimulants, and concentrated foods. Complications are treated according to general rules.

Scalds of the glottis are due to the inhalation of steam or of ignited gas. A child may scald the glottis by trying to drink from the spout of a kettle (Moullin). The symp

toms are pain, dysphagia, and dyspnea. Edema of the glottis comes on quickly. The treatment is tracheotomy or intubation of the larynx in severe cases; in mild cases, scarification of the larynx.

Effects of Cold.-Local Effects.-Cold produces numbness, pricking, a feeling of weight, redness of the surface followed by stiffness, local insensibility, and mottling or pallor. Sudden intense cold causes the formation of blebs, the coagulation of blood in the superficial veins, and violent pain in the limb. Cold locally produces frost-bite (page 128). The constitutional effects of cold are at first stimulating, then depressing, and are exhibited by uneasiness, pain, and an intense drowsiness which, if yielded to, is the road to death by way of internal congestion. Death from prolonged cold resembles in appearance death from apoplexy. Death from sudden and overwhelming cold is caused by anemia of the brain from weak circulation and capillary embolism. To bring a partly-frozen person into a warm room may cause death by embolism.

Treatment.-Frost-bite is treated as outlined on page 128. When a person is nearly frozen to death place him in a cool room, but under no circumstance in a cold bath, make artificial respiration, rub him down with flannel soaked in alcohol or in whiskey, and follow this by rubbing with dry hands. After a time wrap the patient in warm blankets and give an enema of brandy. Mustard plasters are to be applied over the heart and spine. As soon as swallowing is possible brandy is administered by the mouth. As the condition improves gradually raise the temperature of the room and give hot drinks.

Chilblain, or pernio, is the secondary effect of cold. It usually appears as a local congestion upon the toes, the fingers, or the nose, and it is apt now and then to inflame and ulcerate. A chilblain is apt to become congested by approaching a fire or by taking exercise, and when congested it itches, tingles, and stings. Frequent attacks of congestion produce crops of vesicles; these vesicles rupture and expose an ulcer, which in rare instances sloughs.

Treatment.-Prevent congestion of the legs and feet if chilblain affects the toes. Order large shoes and woollen stockings and forbid tight garters. The patient with pernio must take regular outdoor exercise and must not loiter around a hot fire. Every morning and evening he should take a general cold sponge-bath, following by rubbing with alcohol and frictions with a coarse towel, and he should