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.