BURNS AND SCALDS, CONTUSIONS AND BRUISES
BURNS AND SCALDS
Burns and Scalds are lesions characterised by a more or less marked
destruction of the tissues of the body, caused by the action upon its
internal or external surfaces of a temperature higher than that of the
body itself, or by the action of corrosive chemical substances.
=Burns= are produced in the following ways:
By exposure to radiant heat.
By the direct application of flame.
By contact with heated solids.
By contact with solid bodies which have become liquefied
by heat, such as metals in a state of fusion.
By friction.
By lightning, electricity, and X-rays.
By contact with corrosive chemical substances,
solid or liquid.
=Scalds= are produced by the application of heated liquids, at or near
their boiling-points, or in a gaseous form--as _steam_.
The injuries produced will depend upon the degree of temperature, the
period of exposure to its action, and the extent of surface involved.
The danger to life depends more on the extent of surface injured
than the intensity of the burn or scald upon a limited area, unless
the position of the burn render it peculiarly dangerous. Even though
the injuries be comparatively superficial, if they involve one-third
or one half of the surface of the body they must be regarded as
fatal. They may prove fatal by shock, by asphyxia, by constant and
profuse discharge from the injured surface, from absorption of septic
matter, from secondary inflammations of internal organs and serous
membranes--pleurisy, peritonitis, meningitis, perforating ulcer of
the duodenum. Children succumb more quickly than adults to burns and
scalds--the simplest, in their case, often proving fatal.
The cause of early death from burns and scalds is looked upon as a
disorder of the blood following injury to the red corpuscles by the
heat, and that this is more easily brought about in children, because
of the thinness of the skin, and the red corpuscles being less capable
of resistance.
The following table gives the different degrees of burns:
1. Superficial inflammation, characterised by redness without
blistering.
2. Acute inflammation, the epidermis raised, forming vesicles
containing serum.
3. Destruction of the superficial layers of the true skin.
4. Destruction of the true skin and subcutaneous cellular
tissues.
5. The superficial and deep parts converted into a charred mass.
6. Entire carbonisation of the parts.
(Dupuytren.)
Post-mortem Appearances
These will vary according to the extent of the injuries, the length of
time the individual lived after receiving them, and the causative agent.
=External Appearances.=--1. _Burns._--Radiant heat whitens the skin,
flames blacken it, from deposit of carbonaceous material. The hair
and clothing of the body are singed. Blisters may be present on
various parts, and roasted patches of the skin or deeper parts may
be present. The flame of an explosive, such as a mixture of coal gas
and air, scorches and mummifies the skin. The skin is blackened by
the explosion of gunpowder, and particles of the powder may be driven
into it; similar results follow explosions in coal mines, but to a
greater degree. Burns caused by red-hot solids or molten metals vary
in appearance according to the length of time they have remained in
contact with the surface: if short, there may be injury to the skin
only, with blistering; if for a longer period, there will be roasting
or charring of the part, and blisters may not be present.
All stages of burns may be present.
The uncovered parts of the body, as a rule, are more affected than the
clothed, unless the clothes become ignited, when the converse would
hold good. In cases where the clothes have been saturated with an
inflammable oil like petroleum the burns are much more severe.
2. _Scalds._--The appearances produced and the severity of the result
will vary directly with the boiling-point of the liquid. Boiling water
and steam produce vesication; the hairs are not affected. If the steam
be superheated, blistering may be absent, and the skin appear sodden
and devoid of elasticity. If the person survive the injuries for some
days, the skin will present appearances of reaction. After exposure
to great heat the bodies of the victims are usually contorted, with
the limbs flexed and the arms fixed in a defensive attitude--the
“pugilistic attitude.” This condition is due to _heat rigidity_.
=Internal Appearances.=--The brain is shrunk, usually without any
alteration in form, the lungs also shrunk, and the larynx, trachea,
and bronchi may contain carbonaceous material; their membranes may
be injected and covered with frothy mucus. The kidneys may present
reddish-brown markings from altered blood, and degeneration of the
epithelium of the tubules and Malpighian bodies.
There may be a reddened appearance of the mucous membrane of the
stomach and intestines, and in a certain number of cases, where death
has occurred some time after the injuries, ulcers may be present in the
duodenum.
The uterus and testicles resist the action of fire in a marked degree,
and may be changed but slightly, although the rest of the body has been
almost consumed.
The blood of persons who have been exposed to the action of CO during a
fire will present the usual cherry-red colour and the spectrum of COHb.
A similar cherry-red colour of the blood is found in bodies of persons
burnt to death which is not due to the action of CO. The cause is a
physical one, the alteration in colour being due to the coagulation of
the albumin in microscopical particles by the heat. In this condition
the spectrum is that of O₂Hb, and can be reduced in the usual way. The
same peculiar condition of the blood may be produced in corpses by
exposure to a sufficiently high temperature.
If on the examination of the blood COHb is detected, it indicates that
the person in whose body it is found was alive during the progress of
the fire.
_Corrosives._--The appearances produced by the application of corrosive
chemical substances are peculiar to them, and depend upon their special
actions upon the tissues. Sulphuric acid acts by rapidly extracting
water from the tissues and producing local rise of temperature; nitric
acid combines with the tissues to form picric acid; nitrate of silver
acts upon the tissue by hyperoxidation, and combines to form albuminate
of silver, nitric acid being liberated. A solution of phosphorus in
carbon disulphide, known as Greek fire, by the rapid oxidation and
burning of the phosphorus produces combustion of the tissues.
The diagnosis of lesions produced by corrosives from those by fire
or heated fluid or steam rests upon the absence of vesication, the
presence of the stains on the skin or clothing which they produce, and
the chemical analysis of the stains. Sulphuric acid produces a grey
or brownish-black eschar on the body; hydrochloric acid may leave a
whitish-grey stain; nitric acid produces a yellow stain on the skin,
and may produce sloughing.
=Was the burn inflicted before or after death?=--The answer to this
question depends upon careful consideration of all the evidences
afforded by the external and internal appearances, and upon the
presence or absence of _vital reaction_ in the lesions found.
Two characteristic appearances--redness and vesication--are present in
burns inflicted during life when the surface of the body is not charred
and the tissues destroyed. The redness affects the surface and entire
substance of the true skin, which is dotted by the deep red openings
of the sudoriferous and sebaceous ducts. This appearance cannot be
produced after death. Blisters are formed by a temperature somewhat
less than that of boiling water. Vesication, according to Orfila,
is characteristic of a burn inflicted during life, and the late Sir
Robert Christison found that in burns caused before and after death the
vesicles in the former contained serum, the latter air. In anasarcous
subjects, however, serous blisters may be formed, especially if the
heat employed be not too severe. A case is recorded by Taylor in which
vesicles containing bloody serum were formed on the body of a man who
had just been drowned and who had been put into a hot bath.
Ante-mortem vesicles in which vital reaction has taken place present
the following characteristics:
(_a_) They contain serous fluid in which albumin and
chlorides can be detected.
(_b_) An inflammatory red bounding line round the
circumference.
(_c_) Inflammatory redness of the base, and the papillæ
of the skin.
(_d_) The presence of pus, which would indicate that
the person had lived at least thirty-six hours after
the burn had taken place.
In burns produced after death, the surface and substance of the skin is
of a dull white colour, dotted with grey openings of the sudoriferous
and sebaceous ducts, and the subcutaneous tissues are uninjected.
Vesicles produced by burns may have to be distinguished from the
phlyctænæ, the result of advanced putrefaction. The latter possesses
none of the characteristics of the former.
If a vesicle present the following characteristics it may be accepted
as a post-mortem origin without doubt: if it be small and its contents
scanty, if the fluid it contain be free from albumin and chlorides, if
it contain air, and if there be no signs of inflammatory reaction.
=Was the burning homicidal, suicidal, or accidental?=--No general rules
for guidance can be here laid down. In most cases the conditions under
which the body is found will point less to suicide than to homicide or
accident. In cases of murder, the body is often burnt in the attempt
to destroy all traces of the crime. It must, however, be borne in mind
that intense heat applied to the body may give rise to a wound on the
surface like that caused by a cutting instrument. Casper mentions
such a case, in which a wound was found over the liver, due to the
application of intense heat to the body. The conjunction of robbery
will greatly assist in helping to solve the difficulty. It may be very
confidently stated that to dispose of a body by burning is no easy
matter.
Preternatural Combustibility
The possibility of “spontaneous combustion” occurring in bodies
during life has been mentioned in the earlier writings on medical
jurisprudence, and cases have been recorded in which it has been
alleged to have taken place. Up to the present time no undoubted case
of “spontaneous combustion” during life has been seen. On the other
hand, the possibility of its occurrence is contra-indicated by the
following facts: that the human body must consist of 75 per cent. of
its weight of water, to be compatible with life, and that a dead body
steeped in methylated spirit for many months or even years will never
be consumed, if set on fire, in the rapid and complete manner alleged
as occurring in cases of so-called “spontaneous combustion.”
A case is recorded by Beatson (_B. M. J._, vol. i., 1886, p. 295) of
a man, subject to foul eructations from the stomach, who got out of
bed during the night and struck a match to see the time; while blowing
out the light his breath took fire, producing an explosive noise
sufficiently loud to awaken his wife. Such cases are very rare.
It is a fact that by the action of certain micro-organisms upon organic
matter inflammable gases are produced. That such an occurrence is
possible, in the dead human body, is supported by cases recorded by
Gull (_Med. Times and Gazette_, 1885) and Reynolds (_Med. Chron._,
1891). In Gull‘s case inflammable gases escaped through punctures made
into the abdomen, and they burned spontaneously on contact with the
air. In Reynold‘s case no flames were seen, but extensive and deep
marks of burning were present, especially on the trunk and thighs. It
has been suggested that the habitual use of alcohol in excess during
life renders the tissues of the body more inflammable, but the matter
is not yet decided. Tissues steeped in alcohol are not rendered more
inflammable.
Dr. Ogston, who cautiously avoids committing himself to the belief in
“spontaneous combustion,” yet thinks that the subject of _preternatural
combustibility_ in certain conditions of the body may perhaps, to say
the least of it, be set down as one still _sub judice_. “There is no
evidence to justify the use of the word ‘spontaneous,’ but there can be
no doubt that an extraordinarily high degree of combustibility occurs
in rare instances, to which the term _preternatural_ combustibility
would more correctly apply” (J. Dixon Mann).
Burns due to X-Rays
Over-exposure to the action of X-rays produces burns of a peculiar
character, and in cases of unprotected skin exposed to the action
of the rays in those who are constantly working with them, forms
of dermatitis have arisen which are intractable and tend to become
epitheliomatous in character.
The results of slight over-exposure, or repeated short exposures vary
from a simple redness of the skin to severe dermatitis, the hair of the
part being shed. When the over-exposure or dosage has been severe, the
skin may vesicate and ulcerate. I have seen this in cases where the
rays have been used for reduction of the spleen in leukæmia and Banti‘s
disease. The burns heal with cicatrisation of radiate shape, the skin
around the scar being permeated with numerous capillary vessels which
produce the appearance of capillary nævi, and in other instances
large stellate superficial vessels are formed. In addition, marked
pigmentation of the skin may follow the burn. X-ray burns which have
produced vesication and ulceration or sloughing take a long time to
heal in comparison with ordinary burns.
In repeated exposure to the rays, even when little redness has been
noticed at the time, the formation of capillary vessels may become
evident some time after the exposures have been stopped. This may
cause disfigurement, by the formation of telangiectasis, especially
if they appear on the face or neck. The falling out of the hair is
produced by X-rays as a therapeutic measure in cases of ringworm, and
due precaution must be taken to limit the effect and area of exposure
by proper screening. The same precaution should be used to protect
parts of the body other than the part which requires treatment or
examination in other conditions.
With increasing knowledge of the effects of X-ray exposures, special
precautions have been devised to prevent untoward effects, so that
burns from over-exposure, and dermatitis amongst X-ray workers are
prevented.
CONTUSIONS AND BRUISES
In the living these injuries are accompanied with swelling, pain, and
more or less discoloration of the part affected. Among malingerers it
is not an uncommon practice to bruise the body to imitate the spots
of purpura and scurvy. In scurvy, the condition of the gums common to
that disease, and the state of the general health, will point to the
true nature of the spots. The diagnosis of purpura will be assisted
by noting the diffusion of the spots over the body. In old people
purpuric spots frequently extend round the limbs, chiefly on one of the
lower extremities. Many blood diseases are associated with ecchymoses
and purpuric eruptions. Some persons are very easily bruised, and a
pinch, by no means severe, will cause on their arms a severe bruise.
Discoloration--ecchymosis--may take place in the skin, cellular tissue,
muscles, or internal organs as a result of external injury, or it may
be due to sudden and powerful contraction of a muscle or group of
muscles. Not infrequently the discoloration does not appear over the
seat of injury, but at some distance from it; and when the effusion
is deep-seated, days may elapse before any discoloration of the skin
takes place, and then it is not blue, as in superficial parts, but
of a violet, greenish, or yellowish hue. A deep-seated ecchymosis
may give no external sign of its presence; hence in all cases deep
incisions should be made before an opinion is ventured as to the
entire absence of this occurrence. This is very noticeable among the
deep-seated muscles of a limb. In these cases, forty or fifty days
may elapse before the deep-seated bruise shows its existence on the
surface, and then only as irregular, yellowish, green, or bluish spots
over the part. A very slight contusion, as a sprain of the ankle, may
give rise to extended discoloration of the leg. An ecchymosis is not
necessarily situated directly under the seat of injury. A blow given
during life may not appear as an ecchymosis till _after death_. The
change of colour in bruises begins at the circumference, and travels
inwards. During the first three days the colour of the bruise is blue,
bluish-black, or black; greenish on the fifth or sixth day; and yellow
from the seventh to the twelfth. The extent of an ecchymosis depends
greatly on the looseness of the cellular tissue. A slight contusion
causes a slight redness and swelling, and may leave no mark on the dead
body, unless death has taken place within thirty-six hours. Injuries of
this kind sometimes leave a parchment-like hardness and discoloration
of the skin. The part looks slightly depressed, due probably to the
epidermis having been partly rubbed off, and the skin then drying.
Similar marks are sometimes made by blisters. These marks may be
produced on the dead body by friction and exposure to the air.
The diagnosis of ecchymosis from hypostasis has been given (see p.
46). A tolerably severe blow after death would be necessary to produce
appearances similar to those produced by a slight one during life.
In scourging, there are parallel ecchymosed lines, of small spots
resembling petechiæ. An internal organ may be ruptured, and yet there
may be no appearance of injury externally. The liver is the organ most
commonly ruptured. The rupture is almost always longitudinal, and in
some cases a portion of the gland is more or less detached. The spleen
is also not infrequently ruptured; and this occurs most frequently in
countries where ague prevails. Rupture of the lungs and brain is rare.
When the pelvis is fractured, the bladder is frequently found ruptured.
Death in most cases is due to internal hæmorrhage or shock, when any of
the internal organs are ruptured.
=Can the appearance of a bruise be produced after death?=--It is
possible that the appearance of a bruise inflicted during life may be
produced within two hours after death, and in some rare cases even
after the lapse of three hours and a quarter (Christison); but these
ecchymoses are limited in extent, and when large are due to a rupture
in a vein which can be readily ascertained. The experiments of the
late Sir Robert Christison, relating to this question, are detailed in
the _Edinburgh Medical and Surgical Journal_, vol. xxxi. The amount
of violence required after death to produce appearances like those
made before death is such as would seldom, if ever, be inflicted on a
corpse, and, therefore, where we find a well-marked bruise we ought to
infer that it was made before death.
The following table, compiled from the experiments of Christison, may
assist the diagnosis:
--------------------------------+---------------------------------
During Life. | After Death.
--------------------------------+---------------------------------
1. Swelling of the part. | 1. No swelling.
|
2. Coagulation of the blood | 2. No such appearance, unless
effused into the adjacent | there is a rupture of a large
cellular tissue, with or | vessel in the neighbourhood
without tumefaction. | of loose cellular tissue.
|
3. Incorporation of blood | 3. No such appearance produced
with the whole thickness | by a blow after death.
of the true skin, rendering |
it black instead of white. |
--------------------------------+---------------------------------
_N.B._--Extensive effusion may occur without affecting the skin,
but when the skin is so affected Christison thought it decisive of
_ante-mortem_ injury.
The Size and Form of a Bruise should be noted.
Why?
1. _In Hanging and Strangulation._--The mark due to pressure of
the cord on the neck in hanging runs obliquely round the neck; in
strangulation, the mark encircles the neck. The mark is frequently
interrupted, and may present very varied appearances in different parts
of the neck. The mark of the knot may be found under the chin.
2. _In Throttling._--The pressure exerted on the throat of the deceased
by the fingers of his assailant may leave marks which may point to the
means used to cause death.
3. _In other Cases of Death by Violence._--The impression made by the
weapon used may lead to the identification of the murderer. The marks
left by the wards of a large door-key once led to the identification of
the assailant.