Edward Adams

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.

BURNS OF THE SECOND DEGREE

Pathology.

Clinical Stages.

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.