CHAPTER IX
Burns, Scalds, Frostbites, Etc.
Classes of Burns—Treatment—Burns Caused by Acids and Alkalies—First Aid Rules for Frostbites—Real Freezing—Ingrowing Toe Nail—Fainting—Suffocation—Fits.
BURNS AND SCALDS.—If slight, skin very red, unbroken.
First Aid Rule.—Cover with cloths wet in strong solution of baking soda in cold water. Dry gently, and spread with white of egg, thick.
If deeper, blisters, skin broken, thick swelling; there may be some bleeding.
First Aid Rule 1.—Stop pain quickly. Cut away clothing very gently. Break no blisters. Cover with Carron oil (equal parts of limewater and linseed or olive oil) and light bandage. Give fifteen drops of laudanum[9] every half hour in tablespoonful of water, till relieved in part or three doses are taken.
Rule 2.—Combat shock. If patient is cold, pulse weak, head confused, give tablespoonful of whisky in a quarter of a glass of hot water. Put hot-water bottles at feet.
Rule 3.—Quench thirst with pieces of ice held in mouth or a swallow of cold milk.
See page [174] for subsequent treatment.
A burn is produced by dry heat, a scald by moist heat; the effect and treatment of both are practically identical. Burns are commonly divided into three classes, according to the amount of damage inflicted upon the body.
First Class.—There is redness, pain, and some swelling of the skin, followed, in a few days, by peeling of the surface layer (epidermis) and recovery. Sunburn and burns caused by slight exposures to gases and vapors fall into this category.
Treatment.—The immediate immersion of the part in cold water is followed by relief, or the application of cloths wet with a saturated solution of saleratus or baking powder is useful. Anything which protects the burned skin from the irritating effect of the air is efficacious, and in emergencies any one of the following may be applied: starch, flour, molasses, white paint, or a mixture of white of egg and sweet oil, equal parts. Usually after the first pain has been relieved by bathing with soda and water, or its application on cloths, the employment of a simple ointment suffices, as cold cream or vaseline.
Second Class.—In this class of cases the inflammation is more severe and the deeper layers of the skin are involved. In addition to the redness and swelling of the skin there are present blisters which appear at once or within a few hours. The general condition is affected according to the size of the burn. If half of the body is only reddened, death usually results, and a burn of a third of the body is often fatal. The shock is so great at times that pain may not be at once intense. Shock is evidenced by general depression, with weakness, apathy, cold feet and hands, and failure of the pulse. If the patient rallies from this condition, then fever and pain become prominent. If steam has been inhaled, there may be sudden death from swelling of the interior of the throat, or inflammation of the lungs may follow inhalation of smoke and hot air.
Third Class.—In this class are included burns of so severe a nature that destruction and death of the tissues follows; not only of the skin but of the flesh and bones in the worst cases. It is impossible to tell by the appearance of the skin what the extent of the destruction may be until the dead parts slough away after a week or ten days. The skin is of a uniform white color in some cases, or may be of a yellow, brown, gray, or black hue, and is comparatively insensitive at first. Pus ("matter") begins to form around the dead part in a few days, and the dead tissue comes away later, to be followed by a long course of suppuration, pain, excessive granulations ("proud flesh"), and, unless skillfully treated, by contraction of the surrounding area, leaving ugly scars and interfering with the appearance and usefulness of the parts. The treatment of such cases after the first care becomes that to be pursued in wounds generally (p. [50]), and belongs within the domain of the surgeon.
Treatment of the More Severe Burns.—If the patient is suffering from shock he should receive some hot alcoholic drink, as hot water and whisky, and be put to bed under warm coverings with hot-water bags or bottles at his feet.
The clothing must be cut away from the burned parts with the greatest care, and only a portion of the body should be uncovered at a time and in a warm room. Pain may be subdued by laudanum[10]; fifteen drops may be given to an adult, and the drug may be repeated at hour intervals in doses of ten drops until the suffering has been allayed. Lumps of ice held in the mouth will quench thirst, and the diet should be liquid, as milk, soups, gruels, white of egg, and water. The bowels should be moved daily by rectal injections of soap and warm water. As a matter of local treatment, the surface layer of the skin should be kept intact if possible. Blisters are not to be disturbed unless they are large and tense; if so, their bases may be pricked with a needle sufficiently to let out the fluid contents.
Carron oil (equal parts of olive oil and limewater) has been the common remedy for burns, and it is an efficient, though very dirty, dressing, useful if the skin is generally unbroken. It should be applied on clean, soft linen or cotton cloth, which is soaked in the oil, laid over the burned area, and covered with a thick layer of cotton batting and a bandage. When the skin is denuded, leaving a raw surface exposed, the burn must be treated on the same plan as wounds, and should be kept as clean and free from germs as possible. An ointment made of equal parts of boric acid and vaseline, spread thickly on clean cloth, is a good antiseptic preparation in cases where the skin is broken. It is best not to change the dressing oftener than once in two or three days, unless the discharge or odor are considerable. Fresh dressing is very painful and often harmful.
When the dressing is removed, warm saline solution (one teaspoonful of common salt in a quart of water) is allowed to flow over the burn until all discharge is washed off. Then the raw surface is dusted over with pure boric acid or aristol, and the boric-acid ointment applied as before. The cloth upon which the ointment is spread should be made free from germs by boiling in water, and then drying it in an oven and keeping it well wrapped in a clean towel except when wanted.
The same care is requisite as that described under wounds (p. [50]) in regard to cleanliness.
Very extensive burns are most satisfactorily treated by complete immersion of the burned limbs or entire body in salt solution (same strength as above), which is kept at a temperature of from 94° to 104° F., according to the feelings of the patient. The patient lies in a bath tub on horsehair, or better, rubber mattress and rubber pillows; completely covered with water except the head. The urine and bowel discharges must be passed in the water, which is then changed, and the temperature is kept at an even mark by allowing warm water to continually run into the tub to displace that which runs out. The latter can be arranged by siphonage with a rubber tube. While this method requires more care, and running hot and cold water, it is the most comfortable treatment for these cases, usually attended by awful suffering, and at the same time it is most favorable to healing.
It is beyond the scope of this work to describe the various complications and the details of the after treatment in severe burns, including skin grafting, which may tax all the ingenuity of the skilled surgeon. It is hoped that the foregoing may give a clear idea of the treatment to be pursued in emergencies and may prove of some use to those who may unfortunately be compelled to care for burns during a considerable time without the aid of a physician.
BURN BY STRONG ACID.
First Aid Rule 1.—Neutralize the acid. Scatter baking soda thickly over burn, or pour limewater over it.
Rule 2.—Control pain. Wash off soda with stream of water. Apply Carron oil (equal parts of limewater and linseed oil or olive oil). Bandage lightly.
BURN BY STRONG ALKALI.—As ammonia, quicklime, lye.
First Aid Rule 1.—Neutralize the alkali. Pour vinegar over the burn.
Rule 2.—Control pain. Wash off vinegar with stream of water. Dry gently. Apply vaseline or cold cream.
BURNS CAUSED BY STRONG MINERAL ACIDS OR BY ALKALIES.—If acids are the cause, the skin should not be washed at first, but either chalk, whiting, or some mild alkali, as baking soda, should be strewn over the burn, and then after the effect of the acid is neutralized, wash off the soda with stream of warm water. Dry gently with gauze. Apply Carron oil or paste of boric acid and vaseline, equal parts. If strong alkalies have been spilled on the skin, as ammonia, potash, or quicklime, then vinegar is the proper substance to employ, followed by washing. Then dry gently. Vaseline or cold cream is usually sufficient as after treatment. Limewater is useful in counteracting the effect of acids spattered in the eye. In the case of alkalies in the eye, the vinegar used should be diluted with three parts of water. Albolene or liquid vaseline is the best agent to drop in the eye after either accident, in order to relieve the irritation and pain, and the patient should stay in a dark room.
FROSTBITE, REAL FREEZING.—Nose, ears, fingers, toes; insensible to touch, stiff, pale or blue. Person may be unconscious.
First Aid Rule 1.—Restore circulation. Rub gently, then vigorously, with snow.
Rule 2.—Restore heat very gradually. Sudden heat is fatal. Keep in cold room, and rub with cloth wet with very cold water till circulation is established. Then rub with equal parts of alcohol and water and expose gradually to heat of living room.
Rule 3.—If person ceases to breathe, resuscitate as if drowned. Open his mouth, grasp his tongue, and pull it forward and keep it there. Let another assistant grasp the arms just below the elbows and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest and induces inspiration.) (See pp. [30] and [31].) While this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. Next, let the assistant standing at the head turn down the patient's arms to the sides of the body, the assistant holding the tongue changing hands if necessary to let the arms pass. Just before the patient's hands reach the ground the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. Now, using his knees as a pivot, he will at the moment the patient's hands touch the ground throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. This completes expiration. (A child or a delicate person must be more gently handled.)
At the instant of letting go, the man at the head of the patient will again draw the arms steadily upward to the sides of the patient's head as before (the assistant holding the tongue again changing hands to let the arms pass, if necessary), holding them there while he slowly counts one, two, three, four (about five seconds).
Repeat these movements deliberately and perseveringly twelve or fifteen times in every minute—thus imitating the natural motions of breathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life carefully aid the first short gasps until deepened into full breaths.
Keep body warm after this with warm-water bottles.
FROSTBITE.—The nose, chin, ears, fingers, and toes are the parts usually frozen, although severe results ending in death of the frozen part occur more often owing to low vitality of the patient than to the cold itself. In the milder degree of frostbite there is stiffness, numbness, and tingling of the frozen member; the skin is of a pale, bluish hue and somewhat shrunken. Recovery ensues with burning pain, tingling, redness, swelling and peeling of the epidermis, as after slight burns. The skin is icy cold, white, and insensitive in severe forms of frostbite, and, if not skillfully treated, becomes, later, either swollen and discolored, or shriveled, dry, and black. In either case the frozen part dies and is separated from the living tissue after the establishment of a sharp line of inflammation which results in ulceration and formation of pus, and thus the dead part sloughs off. It is, however, possible for a part thoroughly frozen to regain its vitality.
Treatment.—The essential element in the treatment is to secure a very gradual return of blood to the frozen tissues, and so avoid violent inflammation. To obtain this result the patient should be cared for in a cold room, the frozen parts are rubbed gently with snow, or cloth wet with ice water, until they resume their usual warmth. Then it is well to rub them with a mixture of alcohol and water, equal parts, for a time and expose them to the usual temperature of a dwelling room. Warm drinks are now administered to the patient. The frozen member, if hand or foot, is raised high in the air on pillows and covered well with absorbent cotton and bandage. If much redness, swelling, and pain result this dressing is removed and the part is wrapped in a single thickness of cotton cloth kept continually wet with alcohol and water.
Subsequent treatment consists in keeping the damaged parts covered with vaseline or cold cream, absorbent cotton, and bandage. If blisters and sores result, the care is similar to that described for like conditions under burns. If death of the frozen part becomes inevitable, the hand or foot should be suspended in a nearly vertical position to keep the blood out, and the part bathed twice daily with a solution of corrosive sublimate (one 7.7 gr. tablet to pint of water), dusted well with aristol, and dressed with absorbent cotton and bandage until the dead tissue separates and comes away. If the frozen part is large it may be necessary to remove it with a knife, but this is not essential when the tips of the fingers or toes are frozen.
General Effect of Cold.—Sudden exposure to severe cold causes sleep, stupor, and death. Persons found apparently frozen to death should be brought into a cold room, which should be gradually heated, and the body rubbed with snow or ice water, and artificial respiration employed, as just directed. Attempts at resuscitation ought to be persistent, as recoveries have been reported after several hours of unconsciousness and apparent death from freezing.
CHILBLAINS AND MILD FROSTBITES.—The effects of severe cold on the body are very similar to those of intense heat, though they are very much slower in making their appearance. After a person has frozen a finger or toe he may not notice much inconvenience for days, when suddenly violent inflammation may set in. The fingers, ears, nose, and toes are the members which suffer most frequently from the effects of cold. Similar symptoms of inflammation, described under burns, also result from cold, that is, redness and swelling of the skin, blisters with more severe and deeper inflammatory involvement, or, in case the parts are thoroughly frozen, local death and destruction of the tissues. But it is not essential that the body be exposed to the freezing temperature or be frozen at all, in order that some harm may result, for chilblains often follow when the temperature has not been lower than 40° F., or thereabouts.
The effect of cold is to contract the blood vessels, with the production of numbness, pallor, and tingling of the skin. When the cold no longer acts then the blood vessels dilate to more than their usual and normal state, and more or less inflammation results. The more sudden the return to warmth the greater the inflammatory sequel.
Chilblains represent the mildest morbid effect of cold on the body. They exist as bluish-red swellings of the skin, usually on the feet or hands, but may attack the nose or ears, and are attended by burning, itching, and smarting. This condition is caused by dilatation of the vessels following exposure to cold. It is more apt to happen in young, anæmic women. Chilblains usually disappear during warm weather. Scratching, friction, or the severity of the attack may lead to the appearance of blisters and sores. In severe cases the fingers and toes present a sausage-like appearance, owing to swelling.
Treatment.—Susceptible persons should wear thick, warm (not rough) stockings and warm gloves. The chilled members must never be suddenly warmed. Regular exercise and cold shower baths are good to strengthen the circulation, but the feet and hands must be washed in warm water only, and thoroughly dried. If sweating of these parts is a common occurrence, starch or zinc oxide should be dusted on freely night and morning. Cod-liver oil is an efficacious remedy in these cases; one teaspoonful of Peter Möller's pure oil three times daily after meals. The affected parts are bathed twice daily in a solution of zinc acetate (one dram to one pint of water), and followed by the application, on soft linen or cotton, of zinc-oxide ointment containing two per cent of carbolic acid. If this is not curative, iodine ointment mixed with an equal quantity of lard may be tried. Exposure to cold will immediately bring on a recurrence of the trouble. If the affection of the feet is severe the patient must rest in bed. If the parts become blistered and open sores appear, then the same treatment as for burns is indicated. Wash with a weak solution of corrosive sublimate (one tablet for surgical purposes in two quarts of warm water) and apply an ointment of boric acid and vaseline, equal parts, spread on soft, clean cotton or linen. Rest of the part and existence in a warm atmosphere will complete the cure.
INGROWING TOE NAIL.—This is a condition in which the flesh along the edges of the great toe nail becomes inflamed, owing either to overgrowth of the nail or to pressure of the soft parts against it. Improper footgear is the most common cause, as shoes which are too narrow across the toes, or not long enough, or those with high heels which throw the toes forward so that they are compressed by the toe of the boot, especially in walking downhill.
A faulty mode of cutting the toe nails in a healthy foot may favor ingrowing toe nails. Toe nails should be cut straight across, and not trimmed away at the corners to follow the outline of the toes—as then the flesh crowds in at the corners of the nails, and when the nail pushes forward in its growth it presses into the flesh. Nails which have a very rounded surface are more apt to produce trouble, because then the edges are likely to grow down into the flesh. Inflammation in ingrowing toe nail usually arises along the outer edge of the nail. The flesh here becomes red, tender, painful, and swollen so that it overlaps the nail. After a time "matter" or pus forms and finds its way under the nail, and the parts about it ulcerate, and "proud flesh" or excessive granulation tissue springs up and imbeds the edge of the nail. Wearing a shoe, or walking, becomes impossible. The condition may last for months, or even years, if not rightly treated.
Treatment.—Properly fitting footgear must be worn—broad at the toes with low heels and of sufficient length. If pus ("matter") forms, the cut edge should be raised up by pushing in a little absorbent cotton under the nail every day. Hot poultices of flaxseed meal, or other material will relieve any special pain and inflammation. Soaking the foot frequently in hot water, and observing especial cleanliness, will aid recovery. Tannic acid, or some antiseptic powder like nosophen, should be dusted along the edge of the nail, and the flesh crowded away from the nail by pushing in a little cotton with some tannic acid upon it.
If there is a raw surface about the border of the nail, powdered lead nitrate may be dusted upon it each morning for four or five days, till the ulcerated tissue shrinks away and the edge of the nail becomes visible. The toe should be covered with absorbent cotton and a bandage. As soon as the toe is really inflamed the case becomes surgical, and as such demands the care of a surgeon when one can be obtained.
FAINTING.
First Aid Rule 1.—Remove impediments to respiration. Remove collar, loosen all waist bands and cords, unhook corset or cut the laces at person's back.
Rule 2.—Assist heart and brain with blood pressure. Put cushion under buttocks, wind skirt close about legs, and raise feet in air. Wait ten seconds.
Rule 3.—Aid respiration. Put mild smelling salts under nose. Spatter cold water in face.
SUFFOCATION FROM GAS IN WELLS, CISTERNS, OR MINES, OR FROM ILLUMINATING GAS.
First Aid Rule 1.—Remove quickly into pure air.
Rule 2.—Resuscitate as if drowned. Open his mouth, grasp his tongue, pull it forward and keep it there. Let another assistant grasp the arms just below the elbows, and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting, which enlarges the capacity of the chest and induces inspiration. (See pp. [30] and [31].) While this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. Next, let the assistant standing at the head turn down the patient's arms to the sides of his body, the assistant holding the tongue, changing hands if necessary to let the arms pass.
Just before the patient's hands reach the ground, the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. Now, using his knees as a pivot, he will, at the moment the patient's hands touch the ground, throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. This completes expiration. A child or a delicate person must be more gently handled.
At the instant of letting go, the man at the head of the patient will again draw the arms steadily upward, to the sides of the patient's head, as before (the assistant holding the tongue again, changing hands if necessary to let the arms pass, holding them there while he slowly counts one, two, three, four (about five seconds)).
Repeat these movements deliberately and perseveringly twelve or fifteen times in every minute, thus imitating the natural motions of breathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life, carefully aid the first short gasps until deepened into full breaths.
Keep the body warm with hot-water bottles and blanket.
Rule 3.—Give oxygen to breathe from a cylinder, for two days, at short intervals, in the case of illuminating gas.
FIT; CONVULSION.
First Aid Rule 1.—Aid breathing. Loosen collar, waist bands, and unhook corset, or cut the laces behind.
Rule 2.—Protect from injury. Gently restrain from falling or rolling against furniture; lay flat on bed.
Rule 3.—Protect tongue from being bitten. Open jaws and put between teeth rubber eraser tied to stout string, or rubber stopper tied to stout string.
Rule 4.—Crush pearl of amyl nitrite in handkerchief, and hold close to patient's nose and mouth, till face is red and patient relaxes.
Rule 5.—Let patient sleep after fit without rousing.
FOOTNOTES:
[9] Caution. Dangerous. Use only on physician's order.
[10] Caution. Dangerous. Use only on physician's order.