Burn by electric current from “live wire” carrying 1200 volts. (Original.)
Similar injuries are produced by concentrated caustics, acids, or alkalies, while such materials as phosphorus or sulphur produce deep burns. The burn produced by lightning is rarely deep, although it may be extensive ([Fig. 97]). Persons coming in contact with live wires sustain burns which partake much of the nature of the electric discharge, and are sometimes of a character to deserve the term “brush-burn.” Formerly burns were divided by Dupuytren into six or seven degrees, but this classification is too cumbersome and artificial to be acceptable. Morton’s classification is now everywhere accepted, by which they are divided into three degrees: (1) Dermatitis without vesication. (2) Vesication even to the formation of bullæ. (3) Destruction of the skin, with or without that of the deeper parts, which may include actual carbonization of a limb.
Burns may vary within the widest imaginable limits. To an extensive burn of the surface may be added the features produced by inhalation of smoke, steam, or flame; accordingly the eyes and the mucous membrane of the nose and mouth suffer, the parts becoming chemotic and disfigured, so as to make the individual unrecognizable. Burns constitute one of the most painful and distressing injuries known to the surgeon, particularly when the area is large and the case is complicated by injuries which necessitate more or less prolonged rest in bed. When the body is burned completely around it is difficult to ensure rest without the use of anodynes.
Shock is a marked feature of every serious case of burn or scald, and albumin quickly appears in the urine in these cases. Ulceration of the duodenum may follow extensive injuries of this kind, and is occasionally the cause of death. It is to be attributed to a toxic action produced by absorption of putrid material connected with the surface sloughing process. A temporary diabetes is sometimes noted. Laryngitis, bronchitis, and pneumonia may occur from inhalation of steam or smoke, while the inhalation of flame may bring about a rapid edema of the glottis, which may necessitate tracheotomy as an early and emergency measure. It is generally stated that a burn of the second degree, which even involves half of the surface of the body, may prove fatal; while this is not invariably the case, it is too frequently true, and may afford aid in prognosis.
Burns of the second degree are always followed by exudation with formation of blebs, usually within a few hours. In the more serious cases the exudate may be bloody. Burns of the third degree are necessarily followed by more or less gangrene, and this fact affords the reason for the radical treatment recommended.
Treatment.
—By the time the surgeon is called to treat a burn the first indications are usually relief of pain, and perhaps stimulation for shock. The circumstances attending such injury generally leave the patient in an excited mental condition, and for several obvious reasons it would be well to use sufficient anodyne to tranquillize and give comfort. An excellent application in emergency cases is a saturated solution of sodium bicarbonate, or it may be dusted over the affected surface.
The unpleasant visceral complications that follow burns are due to absorption of decomposing fluids or tissues, so retained or so in contact with readily absorbing surfaces as to produce a more or less violent degree of toxemia. In this way are to be explained delirium, convulsions, or coma, as well as the ulcerative and toxic intestinal symptoms which constitute the distressing complications.[17] For this reason the radical method of prevention is the best; hence whenever there is any prospect of sloughing, or when even the epidermis is so burned as to make it appear that it will soon separate, the best method of treatment is to anesthetize the patient and then with a stiff brush and antiseptic soap scrub the part and remove everything that is at all loose, if necessary even using a wire brush, scissors, or a razor. Beneath every sloughing area toxic absorption will go on, and it will be far better to have fresh raw and bleeding surfaces than those which cover sources of danger; the resultant scar will not be any greater, while the subsequent course of the case will be favorably influenced. Exquisitely tender surfaces thus have their sensibility blunted, and the comfort of the patient is greatly enhanced by thorough cleansing and sterilization; moreover, dressings will not need to be so frequently changed. A soothing, antiseptic ointment should be applied; there are few better than the ordinary ointment of zinc oxide, to which may be added bismuth subnitrate and orthoform.[18] Treatment of this kind would probably not need to be repeated, and the duration of the trouble would be reduced to one-quarter or one-third of the time which would otherwise be required. When actual carbonization has occurred amputation is generally necessary. Diluted solutions of ichthyol have proved satisfactory, and the dressings should be covered with some impermeable material, so as to exclude the air. Another advantage is that the amount of subsequent discharge is limited, and thus there is less need for frequent change of dressings. In extreme cases there is no method which gives so much comfort and certainty as continuous immersion in warm water; to this may be added common salt or some other antiseptic, but the water alone is sufficient, if changed frequently. In burns covering a great part of the body this treatment is the most serviceable. It should be employed until the sloughs have separated and surfaces are granulating and ready for skin grafting. This implies, of course, immersion of the entire body in a bath-tub, the body lying on a sheet fastened to the sides of the tub. The advantage of brewers’ yeast dressing, when sloughs are present, has been previously emphasized in the chapter on Ulcers and Ulceration.
[17] The Poisons Produced in Superficial Burns.—The intoxication which often proves fatal in from a few hours to a few days after an extensive burn of the surface, with its attendant delirium, albuminuria, hematuria, vomiting of blood, diarrhea, etc., is very similar to the acute intoxications produced by bacterial products. The sympathetic nervous system is seriously involved in both. These toxins are evidently the result of hemolysis, and it has been shown that they are slow poisons, especially for nerve tissue, apparently eliminated by the intestines and kidneys, which thus suffer during the process of elimination. This is a more rational explanation than the theories of thrombosis or of alterations in the red corpuscles, which would not account for duodenal ulcers, necroses in the Malpighian bodies of the spleen, etc. These poisons are formed in the burnt area and not externally; hence, if this burnt area be removed immediate death may be prevented, whereas if it be permitted to remain for a few hours it may be too late. The poisons seem to be produced in the skin, as the burning of the muscle is not followed by any such degree of intoxication. They seem to be neither ptomain nor pyridin derivatives, but rather resemble the poison of snake venom. Pfeiffer believes them to be derived from the splitting up of proteids altered in composition by the heat of the burn.