Manual of Surgery, Alexis Thomson [new books to read txt] 📗

Fig. 63.—Cicatricial Contraction following Severe Burn.

In burns of the fifth degree the lesion extends through the subcutaneous tissue and involves the muscles; while in those of the sixth degree it passes still more deeply and implicates the bones. These burns are comparatively limited in area, as they are usually produced by prolonged contact with hot metal or caustics. Burns of the fifth and sixth degrees are met with in epileptics or intoxicated persons who fall into the fire. Large blood vessels, nerve-trunks, joints, or serous cavities may be implicated.

General Phenomena.—It is customary to divide the clinical history of a severe burn into three periods; but it is to be observed that the features characteristic of the periods have been greatly modified since burns have been treated on the same lines as other wounds.

The first period lasts for from thirty-six to forty-eight hours, during which time the patient remains in a more or less profound state of shock, and there is a remarkable absence of pain. When shock is absent or little marked, however, the amount of suffering may be great. When the injury proves fatal during this period, death is due to shock, probably aggravated by the absorption of poisonous substances produced in the burned tissues. In fatal cases there is often evidence of cerebral congestion and œdema.

The second period begins when the shock passes off, and lasts till the sloughs separate. The outstanding feature of this period is toxæmia, manifested by fever, the temperature rising to 102°, 103°, or 104° F., and congestive or inflammatory conditions of internal organs, giving rise to such clinical complications as bronchitis, broncho-pneumonia, or pleurisy—especially in burns of the thorax; or meningitis and cerebritis, when the neck or head is the seat of the burn. Intestinal catarrh associated with diarrhœa is not uncommon; and ulceration of the duodenum leading to perforation has been met with in a few cases. These phenomena are much more prominent when bacterial infection has taken place, and it seems probable that they are to be attributed chiefly to the infection, as they have become less frequent and less severe since burns have been treated like other breaches of the surface. Albuminuria is a fairly constant symptom in severe burns, and is associated with congestion of the kidneys. In burns implicating the face, neck, mouth, or pharynx, œdema of the glottis is a dangerous complication, entailing as it does the risk of suffocation.

The third period begins when the sloughs separate, usually between the seventh and fourteenth days, and lasts till the wound heals, its duration depending upon the size, depth, and asepticity of the raw area. The chief causes of death during this period are toxin absorption in any of its forms; waxy disease of the liver, kidneys, or intestine; less commonly erysipelas, tetanus, or other diseases due to infection by specific organisms. We have seen nothing to substantiate the belief that duodenal ulcers are liable to perforate during the third period.

The prognosis in burns depends on (1) the superficial extent, and, to a much less degree, the depth of the injury. When more than one-third of the entire surface of the body is involved, even in a mild degree, the prognosis is grave. (2) The situation of the burn is important. Burns over the serous cavities—abdomen, thorax, or skull—are, other things being equal, much more dangerous than burns of the limbs. The risk of œdema of the glottis in burns about the neck and mouth has already been referred to. (3) Children are more liable to succumb to shock during the early period, but withstand prolonged suppuration better than adults. (4) When the patient survives the shock, the presence or absence of infection is the all-important factor in prognosis.

Treatment.—The general treatment consists in combating the shock. When pain is severe, morphin must be injected.

Local Treatment.—The local treatment must be carried out on antiseptic lines, a general anæsthetic being administered, if necessary, to enable the purification to be carried out thoroughly. After carefully removing the clothing, the whole of the burned area is gently, but thoroughly, cleansed with peroxide of hydrogen or warm boracic lotion, followed by sterilised saline solution. As pyogenic bacteria are invariably found in the blisters of burns, these must be opened and the raised epithelium removed.

The dressings subsequently applied should meet the following indications: the relief of pain; the prevention of sepsis; and the promotion of cicatrisation.

An application which satisfactorily fulfils these requirements is picric acid. Pads of lint or gauze are lightly wrung out of a solution made up of picric acid, 1½ drams; absolute alcohol, 3 ounces; distilled water, 40 ounces, and applied over the whole of the reddened area. These are covered with antiseptic wool, without any waterproof covering, and retained in position by a many-tailed bandage. The dressing should be changed once or twice a week, under the guidance of the temperature chart, any portion of the original dressing which remains perfectly dry being left undisturbed. The value of a general anæsthetic in dressing extensive burns, especially in children, can scarcely be overestimated.

Picric acid yields its best results in superficial burns, and it is useful as a primary dressing in all. As soon as the sloughs separate and a granulating surface forms, the ordinary treatment for a healing sore is instituted. Any slough under which pus has collected should be cut away with scissors to permit of free drainage.

An occlusive dressing of melted paraffin has also been employed. A useful preparation consists of: Paraffin molle 25 per cent., paraffin durum 67 per cent., olive oil 5 per cent., oil of eucalyptus 2 per cent., and beta-naphthol ¼ per cent. It has a melting point of 48° C. It is also known as Ambrine and Burnol. After the burned area has been cleansed and thoroughly dried, it is sponged or painted with the melted paraffin, and before solidification takes place a layer of sterilised gauze is applied and covered with a second coating of paraffin. Further coats of paraffin are applied every other day to prevent the gauze sticking to the skin.

An alternative method of treating extensive burns is by immersing the part, or even the whole body when the trunk is affected, in a bath of boracic lotion kept at the body temperature, the lotion being frequently renewed.

If a burn is already infected when first seen, it is to be treated on the same principles as govern the treatment of other infected wounds.

All moist or greasy applications, such as Carron oil, carbolic oil and ointments, and all substances like collodion and dry powders, which retain discharges, entirely fail to meet the indications for the rational treatment of burns, and should be abandoned.

Skin-grafting is of great value in hastening healing after extensive burns, and in preventing cicatricial contraction. The deformities which are so liable to develop from contraction of the cicatrices are treated on general principles. In the region of the face, neck, and flexures of joints (Fig. 63), where they are most marked, the contracted bands may be divided and the parts stretched, the raw surface left being covered by Thiersch grafts or by flaps of skin raised from adjacent surfaces or from other parts of the body (Fig. 1).

Injuries produced by Exposure to X-Rays and Radium.—In the routine treatment of disease by radiations, injury is sometimes done to the tissues, even when the greatest care is exercised as to dosage and frequency of application. Robert Knox describes the following ill-effects.

Acute dermatitis varying in degree from a slight erythema to deep ulceration or even necrosis of skin. When ulcers form they are extremely painful and slow to heal. When hair-bearing areas are affected, epilation may occur without destroying the hair follicles and the hairs are reproduced, but if the reaction is excessive permanent alopecia may result.

Chronic dermatitis, which results from persistence of the acute form, is most intractable and may assume malignant characters. X-ray warts are a late manifestation of chronic dermatitis and may become malignant.

Among the late manifestations are neuritis, telangiectasis, and a painful and intractable form of ulceration, any of which may come on months or even years after the cessation of exposure. Sterility may be induced in X-ray workers who are imperfectly protected from the effects of the rays.

Electrical burns usually occur in those who are engaged in industrial undertakings where powerful electrical currents are employed.

The lesions—which vary from a slight superficial scorching to complete charring of parts—are most evident at the points of entrance and exit of the current, the intervening tissues apparently escaping injury.

The more superficial degrees of electrical burns differ from those produced by heat in being almost painless, and in healing very slowly, although as a rule they remain dry and aseptic.

The more severe forms are attended with a considerable degree of shock, which is not only more profound, but also lasts much longer than the shock in an ordinary burn of corresponding severity. The parts at the point of entrance of the current are charred to a greater or lesser depth. The eschar is at first