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.

(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.