labor. Rational psychotherapy exemplified in a sympathetic yet confidential attitude and wise and encouraging counsel should not be neglected.

BURNS.

DEAN T. SMITH, M. D., ANN ARBOR, MICH.

In the treatment of severe burns the following conditions have to be met: Shock, handling of superficial burns, the care of deep burns and skin grafting.

Shock. I have mentioned shock first as it is the first thing to be attended to. Usually the first thing that the physician does, when called to treat an injury, is to set the broken bones, sew up the wounds, clear away the debris from burned surfaces and apply the proper dressing. Friends of the patient and onlookers are distressed by these evidences of injury and are gratified by seeing them attended to. It is far more spectacular to set broken bones, to sew up wounds, to cut away charred tissue and apply clean meat dressings, than to sit apparently idly by your patient, seeing that he is in a proper position, that he is kept warm, and has the proper stimulating measures applied. No doubt, many a life has been sacrificed by this over-zeal to attend to local conditions. The shock, from which the patient might have reacted, had proper means be used, was so increased by the suffering, exposure or anaesthetics that the patient could not react. It will often require more courage to say "wait" than to go ahead.

The treatment of shock from burns does not differ from that due to other causes. Stimulation by the use of strychnine, hot salt solution, per rectum, or by hypo-dermo-clysis may be used. The patient should be kept warm and the foot of the bed raised. If the pain is severe, morphine will be indicated. In burns it acts as a stimulant rather than depressant, as it mitigates the pain and allays. the fear. When the shock is not severe, the advantage of having the local conditions cared for will often compensate for the additional depression that may be induced by such care, but this will not hold true of burns if there is much shock. Someone has said, and said truly, that the burning makes the parts aseptic, so that the early treatment will be to protect the injured parts from becoming infected. and from the air. This will also relieve some of the suffering. The parts may be simply wrapped in sterile dressing until the patient has reacted sufficiently to permit more thorough care.

Reporter

Superficial Burns. A large per cent of the burns that the physician has to treat are superficial; that of the first or second degree. Even in those cases that have deep burns, there are usually large areas in which the superficial layers of the skin are destroyed.

After removing the clothing, cleaning the parts and evacuating the blisters, the first real applications to the burned surface will be made. What shall we use? Household experience and the teaching of the books has been that an alkali will do most to relieve the pain. The housewife with her ammonia bottle, and the physician with his bicarbonate of soda or carron oil are familiar to you all. I have not, in my practice, made any advance in this customary treatment. Cotton is usually used to protect the parts from the air. The carron oil, in spite of its nastiness, has been in my experience, very satisfactory for superficial burns.

Ann Arbor does not furnish very large number of these accidents and most of the cases that we treat come on our hands a few days or a few weeks after the injury when the attending physician finds that the victim is not going to die immediately, and that the burns are too serious and extensive to be properly treated outside of a hospital. The result is that our cases are of the severer types. In their discussion of superficial burns I shall draw from the literature on the subject.

Picric acid is regarded by some men of large experience as the best application throughout the whole treatment of ordinary burns. Sterile gauze saturated with a one per cent solution is applied to the whole burned areas. They regard it as much a specific for burns as many physicians regard quinine for malaria. Others with equally large experience claim that picric acid in some instances does not do as well as carron oil, or other alkali applications. Some caution against using it if the burnt area is large. Several cases of poisoning have been reported. Some patients seem to have an idiocynerasy regarding it. In one reported case, severe symptoms of nausea, vomiting and albuminuria followed its application to a small burn.

I have not had experience with it, but from the totality of evi dence, I am inclined to think the acid is more in favor with men whose experience woud fit them to judge, than is any other preparation. I imagine, that notwithstanding its tendency to stain anything with which it comes in contact, it is neater both for the physician to handle and for the patient than the oil.

Deep Burns. In deep burns where the tissues are charred, many men advocate immediate removal of the devitalized parts. From my observations, I believe the dead tissue should not be removed unti!

the granulations have established a line of demarkation and separate the soft tissues when the fibrous and connective tissues may be cut and the mass removed.

W. L. Estes, in the Therapeutic Gazette, June, 1907, says of these injuries: "Deep burns, those which destroy the whole thickness of the skin at once, are followed in many instances by the formation of a very hard, tough slough, which, on account of the coagulation, of all the albuminoids in the area involved, shrinks and pulls on the surrounding skin so that a feeling of extreme tension results; besides. much suffering is produced from the pressure on the underlying nerve filaments. In a short time this charred area sinks below the level of the uninjured skin, and leucocytes soon migrate in increasing. numbers and try to rid the skin of the dead part; and area of redness and swelling surrounds the slough, which adds to the pain; and so on. This process may be shortened and the pain relieved by incising the dead area down to the living tissues. In cases in which this dead surface has been as broad as six to ten centimeters I have frequently made multiple short incisions through it. These incisions permit much serum and sometimes lymph and pus to exude, and en. able one to disinfect the slough much more thoroughly."

If the skin and subcutaneous tissue is destroyed, suppuration will almost always occur sooner or later. A foul odor always attends this suppuration. When the burnt area is large and suppurating, we first clean the parts with creoline or permanganate of potash. I think the first is more efficient as a germicide and the latter has more effect on the odor. After the cleansing, dressing saturated with calendula in twenty-five per cent solution is applied. This dressing has proven soothing to the patient and stimulated healthy granula. tion. Someone at the hospital instituted the use of ordinary sheet wadding for these dressings. It is sterilized and saturated with the calendula solution. Granulations do not grow into it as into gauze and it does not adhere to the surfaces as does absorbent cotton. In some cases we have used very little antiseptics, the wounds keeping clean and healthy simply with the calendula. In others, bacterial activity would show itself in increased suppuration if the germicides were not used. This difference is due more to general than to local conditions. I believe we are inclined to pay too much atention to the local condition and too little to the general vitality of the patient. Good food, plenty of air and the right internal remedy with reasonable cleanliness will accomplish more than the most rigid antiseptic. regime while ignoring the general hygienic condition.

Skin Grafting. Many of the cases that come to us require skiu

grafting. This is usually done as soon as the slough comes away and a healthy granulating surface is present. The contention that the wound should be clean before the skin grafts are put on has not been fully sustained in my experience. I have found that sometimes there would be more or less pus secreted from the ulcer in spite of any measures that were used to stop it. But after putting on the Thiersch skin graft the suppuration would cease, and at times the skin grafts would hold almost as well as in a clean sore. Of course clean surface is desirable.

Another point in the preparation of the wounds: Some operators seem to desire a granulating surface on which to graft. My experience has been that the grafts hold better when the granulations are curetted away. In one patient a portion of a large ulcer was covered with firm healthy granulations. These we left undisturbed. The balance of the ulcer was curetted because the granulations were exuberant. The grafts held very much better on the part that was curetted than on the other. When I have had to graft on fresh wounds, they have held as well as on the granulating surface. We have had much better results in using Thiersch grafts than by the Reverdin method. I know that other surgeons seem to get good results from simple skin ilets. It is possible that I do not understand the best technique for handling them.

We have had two patients this year in whom the burns were very extensive, seemingly reaching the supposed fatal limit of one-half of the body surface. The larger part of the burns were superficial but in each case were extensive ulcers that taxed the patience and ingenuity of the attendants to care for. When the superficial burns were healed, we sought to cover the ulcers with grafts. This work had to be done by piece-meal. In both of these cases, the ulcers were so extensive and so located that only a portion of them could be protected at once. When this portion was healed so that the patient could lie on it so as to make it possible to bring another area in position to be protected, a new section was grafted. In one patient four seances were needed before the parts were entirely healed. The patient was in a most deplorable and seemingly helpless condition when she came to the hospital. It was eight months before she was well. An incident during her treatment was that she developed appendicitis and had the appendix removed. I do not think her burns, or any suggestion coming from her presence in the hospital was responsible for this trouble. She had had slight attacks before the accident.

The second patient was taken home before her ulcers were all

healed. She and her people became impatient at the apparently slow progress she was making. Her burns, while not much more extensive, were so distributed as to make the case more difficult to handle. She was making a degree of progress that promised an ultimate cure. In both of these cases we were able to get our grafts from unburned areas. In the first case we had taxed a very large portion of the uninjured cuticle before the ulcers were all healed.

I have never used other than auto grafts, except when the vitality of the patient was such that all the skin seemed anemic and inviting infection. In such cases I have used frog skins and in one case skin from a guinea pig. In one case the frog skin grafting was really successful, but as a rule these grafts do not grow. However, they have always seemed to check the suppuration and helped in bringing about a health reaction in the patient. The pig skin was used as an experiment and was partially successful.

I have not tried to be exhaustive in this discussion. Every pharmacy and many physicians have special preparations that are to them the most perfect. I have paid no attention to these but have endeavored to note some things that have been helpful in the treatment of severe burns.

PREVENTABLE IGNORANCE OF THE SOCIAL EVIL.

ROLLIN H. STEVENS, M. D., DETROIT, MICH.

In speaking of the social evil before the American Society of Sanitary and Moral Prophylaxis last year, Dr. S. A. Knopf of New York stated that we should not substitute the word "ill" for "evil," inasmuch as it is an ill and not always an evil, for in so many cases "the perpetrator of the act is not an evil doer or criminal," the unfortunate woman being really innocent, "if not before the law made by man, at least before the higher divine law."

But what is an evil? The sexual act in itself is not an evil, even if it is outside the marriage relation. Society has made it an evil. however. But this is because the evil consists in indulging in that which is not good for society as a whole. Prostitution in itself would not be wrong did not society find itself injured by it, and so forbid it. It is the selfish gratification of a passion at the expense of society. that is evil. Prostitution means sexual excess and disease, which are debasing and antagonistic to society's welfare and progress. There