must be thoroughly cleansed and then dried with hot air, by fanning or with an electric drier, and then the liquid paraffin is applied hot, sometimes in layers with gauze between the layers. The whole part is then gently bandaged with a layer of cottonbetween the paraffin and the bandage. In subsequent dressings the whole wax layer may be easily and gently removed. If infection occurs, the Dakin solution should be used daily before the new dressing is applied; or it may be inadvisable to use the paraffin dressing. When the paraffin dressing is used, ordinarily, it should not be changed for twenty-four hours. With some of the terrible burns sustained by the soldiers in the late war, life seems to have been saved, and discomforts were less under this paraffin treatment.

Sollmann has suggested the use of liquid petroleum as the first layer over a burn and the paraffin coating to follow. The first layer of petroleum prevents the pain from the subsequent paraffin coatings, while the primary paraffin coating is painful. It should be recognized that if the burns are large and multiple, the paraffin treatment is tedious of application. Sollmann also suggests an ointment of three parts of surgical paraffin and seven parts of liquid petroleum as a satisfactory dressing for burns. Surgical paraffin, ready for use for burns, can now be obtained.

The removal of hopelessly necrosed and burned tissue, the prevention and treatment of contractions and scar tissues, and the renewal of motility and function belong to several departments of surgery, and the repair possible is sometimes far beyond expectation.

Burns of the Eye..-If the burn is from acid, the immediate use of cold water and of weak alkaline solutions, as bicarbonate of sodium, is essential. If the burn is from an alkali or from lime, which occurs not infrequently, immediate applications of cold water and weak vinegar solutions are essential. The next treatment should be a few drops of a 4 per cent. solution of cocaine, and then, the eye being gently bandaged with gauze soaked in 3 per cent. boric acid solution, the patient should be transported to a hospital or to an oculist for expert treatment.

TREATMENT OF ACUTE POISONING BY DRUGS

The chemical reactions, the physiologic disturbances, and the toxic symptoms caused by the poisonous drugs are not here outlined, as it is assumed that such knowledge has already been acquired. It is necessary only to recall that the poisonous drugs are primarily irritants, excitants, or sedatives. The irritants may cause local symptoms only or may cause systemic symptoms subsequent to the local irritation. The excitants may or may not cause local irritation, but they more or less seriously stimulate the central nervous system. The sedatives are generally not local irritants, and they depress the circulation and central nervous system.

The symptoms of acute poisoning by drugs, will, of course, vary with the character and activities of the drugs. The severity of the irritant action and the rapidity of the absorption, and hence the rapidity of the development of the symptoms, depend upon whether the stomach is full or empty when the poison is swallowed. The irritants cause pain, vomiting, diarrhea, and more or less (depending on the poison) erosion, perforation and subsequent cicatrices. The most frequent irritant poisons are strong acids, strong alkalies, arsenic (rough on rats), corrosive sublimate, lead acetate, oxalic acid, phosphorus (match heads, ratbane), and potassium chlorate. Arsenic, corrosive sublimate, lead, and phosphorus cause serious symptoms after absorption, more especially liver and kidney lesions.

The excitant poisons stimulate the heart and irritate the brain and spinal cord. Depression may follow such excitement or irritation. The drugs that most frequently cause such poisoning are those containing atropine, scopolamine, and cocaine. Caffeine and volatile oils may cause such poisoning in mild degree.

The sedative poisons may act only on the circulation (as digitalis and aconite), or they may depress the cerebral and spinal nerve centers and secondarily depress the circulation. The drugs most frequently causing this kind of poisoning are bromides, chloral, cyanides (prussic acid), and the opium group.

Aspidium, santonin, thymol and wormseed oil may cause such poisoning. All of the coal-tar drugs (acetanilid, antipyrine, aspirin, phenacetin, etc.), the phenols (carbolic acid, etc.), and all synthetic hypnotics (luminal, sulphonal, trional, veronal, etc.), are depressant poisons, acting especially on the heart. The aims of the treatment of acute poisoning by drugs are: (1) To prevent absorption of the poison.

(2) To neutralize the poison.

(3) To promote the elimination of the poison. (4) To counteract the effects of the poison.

(5) To restore the convalescent patient to health.

1. To meet the first indication the stomach must be rapidly emptied, either by vomiting or by washing it out by means of the stomach tube. Most irritant poisons, unless the stomach is full, have already caused vomiting before the patient is seen. If vomiting is sufficient, warm water drinks should be given, containing an alkali as bicarbonate of sodium if the irritant was an acid, or containing vinegar if the irritant was an alkali, or contuining the special antidote for the poison, if the poison is known. If the poison taken is corrosive, the stomach tube should not be passed. If vomiting has not taken place, an emetic must be given, as mustard water, ipecac in any form obtainable, 0.50 Gm. (71⁄2 grains) of copper sulphate in solution, or 2 Gm. (30 grains) of zinc sulphate in solution. If the poison is not irritant and vomiting does not quickly occur, a hypodermatic injection of the hydrochloride of apomorphine (10 grain) should be given, unless there is great prostration. If there is prostration the stomach tube must be used.

When it is decided that the stomach is empty, morphine should be administered hypodermatically, if the drug was an irritant and severe pain is suffered. Also, if the drug was an irritant, albumin water, milk, or mucilaginous infusions (as starch solutions; flaxseed or slippery elm infusions), should be freely given. If the poison was an alkaloid, tannic acid in water should be administered. If the poison was arsenic, the official antidote ("iron hydroxide with magnesium oxide") should be given in 3 or 4 ounce doses. If the poison was lead

acetate, half a teaspoonful of dilute hydrochloric acid, in water, may be given, well diluted, and repeated several times, and later sodium sulphate, 30 Gm, should be given. If the poison was corrosive sublimate, raw eggs should be quickly beaten up and administered. If the poison was phosphorus, the best emetic is copper sulphate, and after vomiting the stomach. should be washed out with 1-1000 permanganate of potasium solution. Later magnesium or sodium sulphate should be administered.

2. To meet this indication drugs should be administered that combat the effects of the poison after absorption. Many of the irritant poisons cause no systemic effects, as they are not absorbed; the exceptions are: arsenic, lead, mercury and phosphorus. All of these may cause, besides the local inflammation, nephritis and some disturbance of the liver; phosphorus is especially irritant to the liver. There is no drug that will act immediately to counteract these poisons in the system, consequently, the treatment of the pathology caused by these poisons becomes the treatment of the subacute condition and of the convalescence.

Poisons that cause nervous excitement may be combated by the opposite acting drugs, such as bromides and chloral, and, if there are convulsions, chloroform inhalations may be given. Morphine may be advisable, but many times unless the dose is dangerously large it may increase the excitement in these conditions of cerebral irritation. Ergot given intramuscularly is often one of the best sedatives for this kind of cerebral irritation. If circulatory weakness follows the nervous excitement, cardiac stimulants may be needed.

If the poison is a nervous sedative, then neutralizing drugs are indicated, as atropine, caffeine, strychnine, camphor, and, in circulatory depression, suprarenal and pituitary, all given hypodermatically.

3. To meet the third indication, besides evacuation of the stomach, quick acting cathartics should be given, and saline cathartics are generally the most useful. Unless there is severe pain, as in irritant poisoning, necessitating the early administration of morphine, catharsis should be caused before the seda

tive is given. If it is considered that there has been much erosion from an irritant drug, and the irritant has been long enough in the stomach to have perhaps passed into the duodenum, castor oil is the best cathartic; later olive oil and mineral oil may be given for the soothing effect. If a drug is slowly eliminated, the patient should be given large amounts of water, both by stomach and by rectum, especially if the poison is arsenic, mercury, or phosphorus. In corrosive sublimate poisoning this treatment should be continued sometimes for days; even the Murphy drip treatment may be advisable.

When a coal-tar or synthetic drug has caused poisoning, sodium bicarbonate solutions should be given freely, as this alkali seems to neutralize the effect of these drugs, especially on the heart.

4. The most frequent primary symptom of poisoning, unless it is of the sedative class, is pain, and pain, if severe, must be quickly stopped before it has caused shock and circulatory depression. Chilling of the body should not be allowed, and unless the poison taken was a nervous excitant or irritant, the patient should be surrounded with hot water bags, as most serious poisoning is followed by collapse, shock, and great loss of heat from the body. Any drug which will combat the physiologic activity of the poison should be utilized. Cerebral excitants should be combated with depressants, cerebral depressants with cerebral excitants, and cardiac depressants with cardiac stimulants. In treating circulatory weakness or heart failure, warmth to the body and dry heat over the heart are valuable aids in causing improvement. The drugs to meet this kind of circulatory failure are those that act quickly, and most treatment must be given hypodermatically. Atropine, caffeine and strychnine are the drugs first to be considered, unless the patient is already in an excited condition and the poisoning has caused cerebral excitation. Sterile solutions of camphor, ergot, pituitary, and suprarenal extract may be used. Strophanthin may be given intravenously in a dose of 1500 of a grain.

It is not advised that all of these drugs be used on the same patient at the same time, but a wise choice should be made; too much should not be done. Great reliance should be placed