+BURNS, FROST BITE, ETC.+
Among the causes of burns are: steam; hot water; melted glass, wax,
rubber, sugar; molten metal; red-hot metal; gas and flame; burning
wood, paper, clothing; electricity; X-ray; ultra-violet ray;
chemicals; acid sulphuric, trichloracetic acid, common lye; alkalis;
carbolic acid; iodin; croton oil, mustard, cantharides.
From these various causes there is very little difference in symptoms,
course, pathology, and treatment. The molten lead burns are usually
small in area, but of the third degree. The underlying tissues are
often devitalized, especially around the feet, making a deep, pale,
slow-healing ulcer. The same is true of many burns from electricity.
The effects of X-ray burns are only seen after several days or weeks
and stubbornly resist treatment. Ultra-violet ray burns may not show
any effects at first, but develop symptoms in about six hours,
sometimes accompanied by great pain. Such burns may be due to sunburn
or powerful electric light.
The epidermis contains no blood vessels, but the mucous layer has
lymph spaces between the cells, draining into the lymph spaces and
channels of the dermis. Nowhere in the body are nerves more abundant
than in the skin. Here we have nerves of motion to the muscles of the
skin; nerves of pain, temperature, and touch; forming an intricate
plexus of nonmedulated fibres sending their branches upward into each
papilla, and even to the mucous layer of the epidermis. Vasomotor
nerves supply the coats of most blood vessels of the skin, and trophic
nerves are everywhere controlling the nutrition of each part. When it
is considered what a complex organ the skin really is; how delicately
its parts are adjusted to the body; how extremely sensitive its nerve
supply, slight stimuli bringing responses and causing reflex action in
far distant organs; how many the uses of the skin (protection,
excretion, expression, and sensation in various forms), it can readily
be understood how great is its importance, and the far-reaching
results of its serious injury.
Burns are classified into three degrees: first, second and third. In
every burn there are two layers of tissue to be considered: _first_,
the layer destroyed—the dead flesh; _second_, the layer injured—the
sick flesh.
+BURNS OF FIRST DEGREE+
+Pathology.+
(1) Destruction of the cells of the horny layer.
(2) Injury of the cells of the mucous layer with an excess of
lymph. No blistering.
(3) Congestion of the subpapillary plexus with some
destruction of the hemoglobin.
(4) Closing of the ducts of the sweat and oil glands.
(5) Slight edema of the underlying dermis.
+Clinical Stages.+
1st stage—hyperemia and pain.
2nd stage—edema.
3rd stage—peeling and staining the skin.
4th stage—cells of the horny layer replaced by pushing upward
of cells from stratum lucidum.
BURNS OF THE SECOND DEGREE
+Pathology.+
(1) Destruction of cells of horny layer and sometimes of the
germinal layer.
(2) Great exudation of fluid composed of lymph, fibrin, and
broken-down cells in the lymph spaces of the mucous layer, forming
blisters.
(3) Intense swelling and congestion of the papillary layer.
(4) Swelling of the connective tissue and elastic fibres in the true
skin.
(5) Thrombosis in some superficial blood vessels.
(6) Leucocytes poured out around the blood vessels.
+Clinical Stages.+
(1) Stage of blistering, edema, dermatitis, toxemia, pain,
chill and shock.
(2) Discharge or absorption of contents of the blister with
shedding of dead layers of epidermis.
(3) Reproduction of cells of the mucous layer from those of
the germinal layer, which have formed the floor of the
blister.
+BURNS OF THE THIRD DEGREE+
+Pathology.+ Charring of the whole skin through the reticular layer, or
deeper. It may involve only skin, or include any underlying
structures, fascia, muscles, blood vessels or bone. The essential
feature is the total death of hair follicles, oil and sweat glands,
with consequent destruction of all germinal epithelium.
+Clinical Stages.+ (1) Stage of destruction of tissue with underlying
inflammation. If extensive, this degree of burn causes shock, probably
non-toxic. During the early stage there is apt to be great pain from
injury to the nerves in the sick layer, but not so great as in that of
second degree burns where the number of injured nerves is greater.
(2) The general effects (toxemia, blood changes, embolism, congestion
of vital organs with resultant chill and shock) are probably little
different from those in extensive burns of the second degree, as few
burns are purely third degree burns, but if extensive they have also
large areas of second degree burns.
(3) Stage of sloughing. During this stage the second degree portion of
the burn passes through its various stages and heals. The dead tissue
shows at its edges a line of cleavage from the surrounding living
skin. The slough is usually slow in coming away, owing to the
direction of the connective tissue and elastic fibres which bind it to
the underlying structures. This last stage lasts from one to three
weeks. The process is more rapid in infected burns and the depth of
this burn will depend upon the degree of heat to which the part was
subjected, the length of time the heat was applied, and several other
factors. The danger of infection is always great owing to: (a)
presence of dead tissue; (b) the low resistance of adjacent sick
tissue; (c) the open veins and lymph channels; (d) the adjoining skin
which is difficult to sterilize; (e) the discharge of a large amount
of serum which forms an excellent culture medium. There may be also
severe hemorrhage as in any sloughing wound. The danger of this is
greatly increased by infection, which breaks down the thrombi in the
veins and arteries.
+Stages of Granulation.+ The cavity left by the slough rapidly fills
with new granulations. These have a tendency to rise above the
surrounding skin.
+Stage of Epidermis Covering.+ If skin grafting is not done, the new
epithelium can be renewed only from the edges—a slow process often
requiring months to cover the whole surface. Coincident with this
stage is the stage of cicatrization. The granulations which fill the
space left by the slough soon begin to contract—nature’s effort to
fill the gap. The granulations are irregular and abundant and for this
reason the scar resulting from a burn is irregular, uneven, inelastic,
contracted, distorted, protuberant and disfiguring.
+Duration.+ First degree burns get well in a few days; those of second
degree, in about from seven to fourteen days, and the healing of the
third degree burns depends upon their extent and depth, severe ones
requiring a very long time. As to scarring in a burn of the third
degree, you can always predict it, although this can be minimized by
early skin grafting.
+Treatment.+ The local treatment is to be directed toward the limitation
of the resulting inflammation; the prevention of septic infection;
assisting the normal elimination of the eschar; the development of
granulations and limitations of the deformity.
In burns of the first degree little or no treatment may be requisite;
a mild dusting powder such as boric acid or sodium bicarbonate may be
used, or picric acid in the strength of from half to one per cent.; a
5 per cent. boric acid ointment is also to be recommended.
Burns of the second and third degree require a different treatment.
Suppose we are called to treat a severe burn of the second or third
degree and find the patient suffering agonizing pain with oncoming
shock and a chill. At once administer a hypodermic of one quarter to
one half a grain of morphine; 1-40, to 1-20 grain of strychnine; and 1
to 1-100 or 1 to 1-50 grain of atropine. To stop the pain and combat
shock, have the room warm, clear it of unnecessary furniture; order
hot water bottles, and, if necessary, give a hypodermoclysis or a
Murphy enema.
In a severe burn three things are more important than the local
treatment: (1) to stop the pain; (2) to combat shock; (3) to provide
for dilution and elimination of the toxins, which are thrown into the
blood.
After having carried out the instructions given above, then proceed to
do the local dressing. The clothing should be carefully cut away—never
pulled off, or dragged over the burned area. A burn is at first
sterile, and we must try to keep it so. Unless we believe that it has
become infected through dirty handling, or by having had dirty
clothing dragged over it, or a dirty blanket laid on it, it is best
not to wash the burn. Pieces of gauze of necessary size are now spread
thickly with an ointment and applied somewhat beyond the burned
areas; over this cotton, and over all a bandage.
The patient is now put to bed, and if shock continues, the normal salt
solution is repeated every eight hours and the patient is given plenty
of water to drink.
Nourishment for the first three days should be liquid, on account of
the intense congestion of the alimentary tract Food is gradually
increased according to conditions. There should be the usual care of
the bowels, skin and kidneys, but in our zeal over the local
treatment, we should not forget that we have to care for a patient
whose blood is loaded with toxins, and whose lungs, stomach, kidneys,
and other organs are congested and filled with emboli. At first, dress
the burns daily, gently wiping away the discharge of serum and broken
down cells, which is poisonous and irritating, with dry gauze or
cotton. Blisters are opened and pieces of loose skin removed with
sterile scissors or forceps, but all skin is left in place as long as
possible to protect the underlying, new forming skin. Every dressing
should be made with a septic care: clean hands, clean gauze and clean
instruments. As soon as the slough begins to form, if there is much
odor, it is well to apply a continuous wet dressing (see later
reference). In case of a burn caused by carbolic acid, the skin is
neutralized by the use of absolute alcohol (95 per cent.). In burns
from trichloracetic acid, use alkaline remedies as sat. sol. of sodium
bicarbonate. Burns from caustic alkalies are neutralized by vinegar or
by some other mild acid such as boric acid. A so-called X-ray burn is
not a burn at all; the observable results of such an accident are not
manifested until several days or even several weeks after the
application of the rays, at which period an inflammatory or a
gangrenous process arises, which begins within the deeper tissues and
subsequently involves the surface. These burns are often accompanied
by loss of hair or of nails in the damaged area; they frequently
remain unhealed for months; if they heal at all, they are very
painful, and are not improved by the treatment which relieves
ordinary burns. In some cases the consequences are very serious.
Ambrine is a newly proposed remedy.
+Effects of Cold.+ The more serious effects consequent upon exposure to
sudden or prolonged cold are termed _frost bite_. In this condition
the feet are commonly affected, and very often the freezing is so
complete that upon thawing, the parts are found to be absolutely dead
or their vitality so impaired by the cold that after reaction,
strangulation and inflammation of the tissues occur, producing
gangrene. As in burns there are three degrees of freezing, viz.,
first, second and third. In the first, the redness, numbness and
tingling which follow exposure to intense cold are succeeded by loss
of power, usually commencing in the toes, and loss of sensation, the
parts becoming anemic and cold. In the second degree the skin is red
or bluish and is covered by blebs with clear hemorrhagic contents. If
the epidermis only is lifted up there is quick, scarless healing, but
in the majority of cases the deeper tissues are involved. In frost
bites of the third degree there are blebs and crusts which eventually
mortify. Parts hopelessly frozen are at first anemic, cold and
insensible but after reaction sets in they become swollen and
discolored or they shrivel up and contract. It is not unusual for the
part to show no change for some days and then to become blue or black;
a line of demarcation forms and the dead tissue sloughs off.
+Treatment.+ Reaction must be gradual. The room should be of low
temperature; the affected part should be immersed in ice water; gentle
friction or rubbing lightly with snow is oftimes efficacious. When the
temperature is normal, stimulating friction with soap liniment,
alcohol, and water and spirits of camphor with elevation of the parts,
is advisable. The room may be gradually warmed and the parts exposed
should then be covered with cotton. As reaction progresses warm,
stimulant drinks may be cautiously administered. If excessive reaction
takes place, evaporating lotions of alcohol and water may be used.
Where a large surface is frozen, prolonged immersion in a bath may be
employed after reaction has been established. When gangrene is
present, surgical intervention is imperative.
+Chilblain+ occurs in individuals with a feeble circulation or in the
anemic or strumous, though healthy young people are not immune. The
feet are very often attacked, especially the heel and the borders of
the feet, but any of the peripheral parts may be affected. The areas
are bluish or purplish red, swollen, cold to the touch, tender,
itching and burning. Neglect and friction will produce severer grades
of inflammation, with vesicles, bullae, pustules and ulceration or
even gangrene, with or without the formation of bullae. There may be a
favorable termination or fatal septicema may supervene.
+Treatment.+ This should be preventive by protecting the feet, wearing
warm clothing, by exercise, and the administration of tonics. Local
immersion of the affected part in hot saturated solution of alum
relieves the venous congestion and the itching. In severe cases,
heating too rapidly, or overheating, should be prevented so as not to
restore a too rapid reaction. A strong faradic current, ten minutes
thrice daily, or the electric bath, ten to fifteen minutes daily, is
beneficial. In ordinary cases, balsam of Peru or 10 per cent. ichthyol
ointment, rubbed in, is all that is required. When there is
ulceration, antiseptic dressings should be applied.