REPORT ON BURNS AND SCALDS.

689

A LETTER TO

JAMES HEYGATE, M.D., F.R.S., President of the Provincial Medical and Surgical Association,

AND TO

CHARLES HASTINGS, M.D., F.L.S.,
President of the Council of the Association,

ON THE BEST METHOD OF

PREPARING A REPORT ON BURNS AND SCALDS.

GENTLEMEN,

I beg to thank you for the honour conferred upon me, in authorizing me to draw up a "Report on Burns and Scalds" for the Association over which you preside, and for the appeal* you have made to the members for contributions of facts, and for assistance in my enquiries.

Before I proceed to state the course which I intend to pursue in my enquiries, and what the nature of those enquiries will be, it seems desirable that I should say a few words in explanation of my opinions on the collection of information by means of Associations of practitioners, and the rules to be observed by the reporter in making use of such information as the profession may please to communicate to him. I cannot unfold, to my own satisfaction, my proposed plan of procedure without stating the circumstances which led me to recommend it to the Provincial Association for their adoption.

collection of medical facts as the Provincial Association. The number of beds in the provincial Hospitals is nearly as great as in the metropolitan, and most of the officers of the former are members of the Provincial Association; besides which, the 1700 members of the Association are distributed through a population of not less than fourteen millions."*

It appeared to me, that instead of trying to obtain monographs or essays, it would be much better if the Association would fix upon some one practical question and investigate it for twelve months; for there are many excellent practitioners who have not time to prepare elaborate reports, who would, however, be able to state in a few words, the results of their observation of the value of particular plans of treatment. If a thousand or eighteen hundred practitioners could have their attention directed during the same period to one and the same disease, a great many practical suggestions must transpire. The labour entailed upon each individual would be most inconsiderable, while the aggregate amount of their communications would probably be of great value. It was by such considerations as the above, that I was led to recommend the plan which the Association has appointed me to carry out. In order to give the plan a fair trial, it is necessary that the disease selected for investigation shall be a very common one, so that all the members may have something to say respecting it,

Perhaps there is no common disease, however unim

It was in 1843, that my attention was first directed to the large amount of valuable practical information which is allowed to run to waste by Provincial Practi-portant it may appear in an individual case, which tioners; and I printed in the Provincial Journal, for is not very important, when we multiply the amount February 3, 1844, a scheme for preserving at a small of pain or inconvenience by the number of those who cost, the papers read before the Medical Societies of labour under it. If this opinion is correct, the Prothe provinces. But it was evident to me that set-essays vincial Association would do well to try to advance 'on diseases were not the best means of eliciting the the art of medicine by investigating common diseases. large amount of practical knowledge possessed by provincial practitioners. I turned my attention to the Provincial Association, (of which, I was not at that time a member,) and in it I thought that I saw a confirmation of this opinion; inasmuch as the members of the Association did not contribute annually as many practical facts to their "Transactions," as were contributed by Guy's Hospital, to its "Reports." Yet the organization of the Provincial Association struck me as being most perfect, and capable of producing contributions on practical points, equal, if not superior, to those of any other Society. In a letter to Dr Hastings, I remarked, "It appears to me that there is no society in the world so admirably adapted for the

Notice to Members.-Mr. Crompton, of Manchester, being appointed to draw up a report on burns and scalds, embodying, as far as possible, the experience and opinions of the profession, we the undersigned, earnestly request that the members of the Association will afford Mr.

Crompton such information on the subject, as they may be
possessed of, and that they will further his inquiries by every
means in their power.

JAMES HEYGATE, M.D.
CHARLES HASTINGS, M.D.

Again; we see in systematic works, and in the journals of the day, recommendations of new remedies, or of new modes of using old ones. Many persons adopt those recommendations, and yet they do not take care to inform the profession of their success with them. In this way medicines obtain a traditional reputation, which is perpetuated in books and lectures. In order, however, to reform our treatment of disease, it is necessary to have a number of observers, whose attention shall be specially directed to the same subject at the same time, and they should have the means of communicating with each other from time to time, and of comparing notes. The Provincial Association consists of a body of such observers, scattered through an immense population. These observers are for the most part plain practical men, well qualified by their experience to give an opinion on the value of any

Quoted by Dr. Hastings in a letter to the Provincial Journal, February 3, 1844, page 354.

+ Mr. Hunt, of Herne Bay, proposed a plan subsequently, which agrees with mine in many respects. As he is working out his plan, I need not allude to the differences in our schemes, as they will soon manifest themselves.

tive opinion must be admitted to be of very great The Journal of the Association affordes an

value.

admirable medium for working the plan; for by the publication of the information obtained from month to month by the reporter, the subject would be kept constantly before the members, and some new practical suggestions would arise out of so many minds directed to one subject at the same time.

method of treatment, or on any remedy, whose collec- | burns and scalds than for an inflammation arising from any other cause."-Works. 1837. vol. iii., p. 265. Mr. Henry Earle says,-" Burns is a subject which well merits your most serious attention, not only from the frequency of its occurrence among the labouring poor, but likewise from the fatal results which so frequently follow, and the calamitous deformities and lameness which so often ensue, should the patient survive the injury. It is, I conceive, most desirable to establish some fixed and settled principles to regulate your conduct in these cases, more especially as so many and such opposite plans of treatment have been adopted at different times; and even at the present day the opinions of practitioners are at variance, and the treatment followed in different institutions is very opposite and uncertain."-Earle on Burns, 1832. p. 2.

One reason for extending the inquiry over a year was to enable the practitioners to record and watch more accurately the cases occurring within that period. A great many do not preserve notes of their cases, and therefore they could speak only from memory as to the cases they had seen in past years.

The communications should be printed in the Journal as soon as they are received, either entire or condensed, according to the space at liberty.

In drawing up the Report at the end of the year, each contributor will be mentioned, and the facts will be given, as far as practicable, in the words of the narrator.

In considering what would be the best subject for the trial of the foregoing scheme, I could think of none which seemed so suitable as the treatment of burns and scalds. They are very common, and therefore every one has something to say on the subject. They are very fatal, and therefore of very great importance. In a letter to me, Mr. Farr observes, "The subject of burns is very interesting. The loss of life is very great. I do not think that the deaths from burus and scalds in the United Kingdom can be less than 4000 per annum."

This subject, however, is important, not alone from the frequency and excessive mortality of burns, but for the extremely unsettled state of opinion respecting the best method of treatment. Since I entered upon this enquiry, Mr. Bransby Cooper has published the following words in the London Medical Gazette, vol. xl., No. 1031, September 3rd, 1847 :

"Common as is the occurrence of burns and scalds

in the practice of every surgeon, I really think, gentlemen, that there is scarcely any class of accidents, for the treatment of which there are fewer or less decided principles laid down. Nor does this arise from the unimportance of their effects, for the amount of mortality resulting from burns and scalds in every institution is so great, that they have always held a prominent place in the list of deaths from accidental causes; and, during the recovery of those who do survive, there often arises the greatest surgical difficulty in endeavouring to prevent the awful contractions which so frequently attend the cicatrizing process.”

Whoever will read the articles on burns in our standard writers, cannot fail to be struck with the want of unanimity of opinion which exists as to the treatment.

John Hunter says,-" There are more remedies for

The subject of burns and scalds, then, is one of very great importance, respecting the treatment of which there is the greatest diversity of opinion: some contending that hot turpentine, and spirits of wine, and alcohol are the best applications; others that cold water is the great remedy; while a third party says that exclusion of the air by cotton, treacle, or any other means, is all that is necessary. I will give no opinion (till the facts are before me,) as to which of these is the correct method of treatment. In appealing to the members of the Provincial Association for facts that may tend to do away with this great diversity of opinion, as to the treatment of burns and scalds, I assure them that whatever communications they may favour me with, shall receive the most impartial and careful consideration in the Report which will be made at the annual meeting of the Association, where every document will be presented for the inspection of the members who are present. As far as it is practicable, the documents forwarded to me will be published in the Provincial Medical and Surgical Journal, and it will serve every purpose if gentlemen will send their communications, direct to the Editor of that Journal. My object will be attained more effectually by the immediate publication of papers, because they are likely to set those into whose hands they come, thinking on the subject, and will thus lead probably to further papers. I do not want to collect a mass of information to be kept in my hands till the Anniversary Meeting, for the purpose of increasing the novelty of my remarks,-on the contrary, I consider that I ought to assist in giving the facts publicity as soon after they reach me as I am able to do. By adopting this course, the members will be able to see the evidence on which the report is founded.

The points which strike me as most deserving of the consideration of the members are the following:1. Whether stimulants (spirit of turpentine, alcohol, ammonia, &c.,) are useful in cases of burns and scalds; and if so, in what cases, and in what manner?

N.B. Dr. Kentish's book led to the general adoption of the stimulating treatment of burns.

BIRMINGHAM PATHOLOGICAL SOCIETY.

12. Give cases of death during apparent recovery from taken from a lady, aged 21.

her friends thought she was suffering from a miscar riage. About three hours before Dr. Fletcher arrived, a nurse had very judiciously applied cold vinegar cloths, which had very much arrested the discharge. On examination per vaginam the neck of the uterus was found ulcerated to a considerable extent. The vagina was plugged with a sponge, the use of the vinegar cloths continued, and perfect rest in the horizontal position enjoined, and a car was directed to be in readiness the next afternoon in order to remove her home, in case there should be no return of hæmorrhage, and the state of the patient equal to the journey of six miles. The next day, all being ready, the patient was placed upon pillows, as nearly in the horizontal position as possible, and removed to her own home, and at once carried to bed, from which she never rose again, except some times when at the best to lie upon the sofa for a short time in her bed-room. About six weeks after the first attack of hæmorrhage she had a second, very severe, when the vagina was again plugged. After this she recovered her flesh very much, and became much stouter; again returns of hæmorrhage reduced her. Occasionally she had very severe pains upon pressure in the region of the uterus, which rendered it necessary to apply leeches and fomentations. All through the disease she was very hysterical; sometimes for days her spirits were remarkably good, and all, to the friends, seemed to be going on well; at other times she was low and so much troubled with hysterical depression and nervous twitching of the muscles of the face and tongue, that it was supposed that a very few days must terminate her sufferings. She gradually became more and more exhausted, and died on the 20th of June, 1847.

and hiccup recurring every few hours; stools pitchy, with small coagula of blood; urine about ten ounces in twenty-four hours, dark-brown and turbid, and of acid re-action; abdomen tumid, with fluctuation; anasarca of lower half of the body; tongue covered with a thick brown fur; pulse frequent and feeble. No material enlargement could be felt in the region of the liver, but firm pressure over the umbilicus detected a hard immoveable swelling. Creasote in cinnamon water; ioduret of mercury inunction; beef-tea injections. The symptoms continued unabated till his death, four days from the above date. Blood-globules were discovered in the dark-brown deposit of the fluids thrown off from the stomach; a large quantity of coagula, of most offensive odnur, and black, passed off from the bowels; he was easiest when resting on his elbows and knees; urine not more than three or four ounces in twentyfour hours. He became extremely feeble and faint, the lips exsanguined, and delirious wandering preceded his death.

Autopsy seventeen hours after death. Considerable emaciation. Head not examined. Chest:-Lungs collapsed but little, adherent on both sides, but most so on the left; the larger bronchial tubes of both were filled with a thick brownish-red fluid, and there was redness of the mucous membrane; the pericardium contained a little clear serum. Abdomen.—Diaphragm adherent to the whole convex surface of the liver, either closely and firmly, or by fine cellular bands; six quarts of thin serous fluid, tinged with bile, were removed from the abdominal cavity; the great omentum enclosed a small quantity of fat; within its lamina were five or six masses of schirrous matter, one by which it adhered to the brim of the pelvis, and another the Post-mortem examination, June 21st.-The consize of a pigeon's egg, close by the transverse colon; tents of the head and chest were healthy. In the around them fat was accumulated, and the vessels were abdomen, the lower part of the peritoneum, the pelvic also congested in a small red patch. In the mesentery portion, was thickened, and bands appeared thrown out, was a chain of these morbid deposits close to the bowel, especially in that part which covers the anterior portion along its whole track, three or four inches apart; they of the uterus between it and the bladder. Of the uterus, were more numerous in the ileum than in the jejunum, about half the upper portion of the body was left, the and each was surrounded by fat, with its patch of copinferior half having been ulcerated away, almost as gested blood-vessels. Some of them projected into the clearly as if cut away, and the perforation of the peri-intestine, had ulcerated, and opened into it with destructoneum, which alone was left, was only prevented by tion of the mucous lining. The contents of the intestine the bands and thickening of the membrane in this part. were mixed with blood, but on washing with a stream of water, the inner coats, except at the points indicated, appeared healthy; in the appendices epiploice of the sigmoid flexure of the colon were also seen similar deposits. The liver was normal in size and texture, of a dark brown colour, not congested; on its whole surface, and throughout its parenchyma, were scattered numerous whitish hard deposits, varying in size from a pin's head to a horse bean, of a round or oval figure; they were also seen in the spleen and tubular structure of the kidneys. But the most remarkable changes were found in the lymphatic glands about the aorta and vena cava, the transverse mesocolon and lesser omentum. They were greatly enlarged, some the size of a pigeon's egg, hard, and when cut into had the ordinary whitish firm texture of scirrhus; they formed a large aggregate mass, surrounding and compressing the large vessels, the duodenum, biliary and pancreatic ducts, and portal

SCIRRHOUS TUBERCLES OF THE LIVER, &c. Mr. Bindley exhibited a specimen of scirrhous of the liver and abdominal glands, pressing upon and obstructing the venous trunks and biliary ducts. He saw the patient only a few days before death, through the kindness of Mr. Jukes, and stated that Mr. W., a confectioner, aged 40, tall and well built, of temperate habits, and previous good health, was attacked about ten weeks ago, after severe mental harass, by the ordinary symptoms of jaundice. The case was obstinate. The stools, from being chalky, became dark-coloured, and contained blood. Vomiting and hiccup came on, the matter ejected being mucas, without trace of bile, and the legs began to swell.

June 18th, 1847. Deep-yellow colour of skin and conjunctiva, with dusky and anxious face; vomiting

SHEFFIELD MEDICAL SOCIETY.›