In trifling burns cold applications are generally used—as immersing the part in cold or iced water. A great variety of remedies are employed, spiritous, watery, acid, alkaline, cold or hot; some apply a coat of cotton or flour, some of tar or pitch, and they state that when these artificial crusts separate, the skin is found healed beneath; in fact, every practitioner, and almost every individual, possesses a favourite application for this very common accident. Some have recommended holding the part to the fire, or plunging it into hot liquid; but this practice, and all similar, are too severe ever to become general, when milder means prove equally effectual. Perhaps the most common applications are, a mixture of lime-water and olive oil, or the ceratum acetatis plumbi. The vesicles, when left to themselves, burst, expose an irritable surface, and the acrid discharge from them excoriates the surrounding skin. Their contents ought to be evacuated by a small puncture, and the cuticle being left carefully undisturbed, a scab soon forms, by which the part is protected while healing. In extensive injuries of the skin, where the cuticle has been altogether destroyed, finely carded cotton is sometimes applied; it is of use in somewhat the same way as the cuticle in the former instance, and being a sort of cushion over the part, prevents it from being irritated by bed or body clothes, or by the patient’s resting on it. It soon becomes soaked with the discharge, and must either be frequently changed, or become a receptacle for pus to putrefy in, and maggots to breed; on account of these circumstances it is objectionable. Dusting the part with common flour, starch, or hair powder, is equally advantageous, and much more convenient; relief is afforded by its immediate application; the parts are cooled; the flour, absorbing the discharge, is soon formed into crusts, which effectually protect the surface; and the after-secretion readily escapes from beneath this, no more moisture being imbibed than is merely sufficient for the encrustation. The artificial covering ought not to be removed until completely detached, by purulent matter accumulating beneath it; then its presence can be of no service, and its removal is accomplished by fomentation or poultice, and without pain to the patient; whereas, by pulling off the crusts shortly after their formation, as some do, whilst they are adherent to the surface, and protecting it from injury, much pain is given to the patient, the raw surface is irritated, and made liable to over-action; a useful application is taken away to make room for another, and, perhaps, not so congenial. After the spontaneous separation, fresh flour may be again sprinkled over the suppurating surface, and, if the affected part is small, it may heal under this application. But when, in burns of considerable extent, suppuration is fully established, and granulations have begun to arise, tepid-water dressing, and lotions, are to be applied as to any other granulating sore; for the reasons already assigned, the applications require to be of a gently stimulating nature.
In severe cases, there is first extreme depression of the powers of life, under which patients sometimes sink; but most frequently this state is obviated by the employment of cordials or stimulants. But these ought to be administered with caution, for reaction soon commences, and often increases to well-marked inflammation, requiring for counteraction low diet, and even bleeding. In such cases gentle laxatives are preferable to purgatives, as by the latter the patient is obliged to make frequent movements, and those are always painful. Stimulants have been strongly recommended, at first powerful, and afterwards gradually weaker, so as, it was said, to restore the balance between the affected parts and the system; and the latter is again to be excited, in order to meet the increased action which the parts assume. The practice is founded on fancy, and cannot become general, being in its first part cruel, and in its second absurd. Whilst debility exists, stimulate cautiously; when over-action ensues, adopt those measures which are best calculated to subdue excitement; this is common sense, and the common practice.
During the process of healing, position of the parts ought to be carefully attended to; contraction of the cicatrices, and cohesion of opposed surfaces often causing unseemly deformities. Surfaces opposed to each other, and naturally separate, may be prevented from uniting by dressing interposed; and contraction of joints is to be guarded against by keeping the limb extended by splints and bandages. Where deformity has occurred, the hardened cicatrix which is in fault may be either divided or excised, and by paying attention to position in the after-treatment, the evil may be greatly lessened. In the case of contracted joints, it is not necessary to excise the whole or greater part of the callous web; simple division is sufficient, if carried deep enough, through the altered and condensed cutaneous tissue. A horrid case of deformity is sketched on the next page, and from a very horrid and atrocious scoundrel, the companion and assistant of Messrs. Burke, Hare, and Co., the Thugs of the Modern Athens. In such a deformity the art of surgery could not avail. In others, however, the cicatrix is not so extensive; it is separated into bands, by the division of which the position of the head and lip is improved, and the comfort of the patient much enhanced. In one case, in which I operated with success very lately, the scar, though extensive, was remarkably soft and pliable, as much so as the finest kid leather.
PART SECOND.
OF PARTICULAR SURGICAL SUBJECTS.
INJURIES OF THE HEAD.
Wounds of the Scalp are attended and followed by more dangerous symptoms than wounds of the integuments on any other part of the body. This is in a great measure attributable to the nature and connections of the parts. The subcutaneous fatty matter is condensed, and closely attached to a firm and unyielding tendinous expansion; and betwixt these tissues and the pericranium, a loose cellular tissue is interposed, so as to allow of free motion of the parts. They are highly vascular, with the exception of the occipito-frontalis fascia, and between them and the internal parts, as is well known, a free communication exists. Injuries of these coverings, though at first apparently trifling, and consequently looked upon as of no importance, and unattended with danger, often assume a very alarming character. No injury of the head, in fact, is too slight to be despised, or too severe to be despaired of.
Punctured and lacerated wounds, more especially those penetrating all the layers of covering, are frequently followed by violent and extensive inflammation of all the tissues, with severe constitutional disturbance, and with delirium and other symptoms denoting functional derangement of the brain. The swelling is often extensive, involving the whole scalp, together with the integuments of the face, and completely shutting the eyelids. In some cases resolution may be accomplished, but the most frequent termination is extensive infiltration of purulent matter into the cellular, or even into the more deep structures, with sloughing of the tendinous expansion. Collections of matter frequently form in the loose cellular tissue of the eyelids, when the parts are affected with inflammation, whether superficial or deeply seated.