William Watson Cheyne.

A manual of surgical treatment (Volume 1) online

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for some considerable tune before the patient can divest himself of his
clothing. Caustic liquids cause extensive sloughs. Red-hot or white-hot
solids cause deep and limited lesions ; fused metals are extremely rapid
in their action and char the parts completely.

X-rays, when applied for a prolonged period, produce symptoms
resembling an acute burn, which, however, do not develop for a week
or a fortnight after the exposure. The skin then rapidly becomes
red, cedematous, blistered, and extremely painful. Under appropriate
treatment this subsides and leaves no ill results beyond a temporary
or permanent epilation. Repeated small exposures to X-rays produce
an entirely different tram of phenomena. The skin becomes glossy
and atrophic, the nails dry, brittle, and cracked, while teleangiectases
and warty growths appear over the affected area ; in severe cases there
may be extensive sloughing and necrosis necessitating amputation, and
in some cases epithelioma of the skin has been produced. When the
patient has been exposed to the passage of a high voltage current,
especially if its action has been prolonged, electric burns are produced
which are generally complicated by ordinary burns produced by ignition of
the clothes. The affected skin is red and cedematous, resembling the con-
dition met with in X-ray burns, but the symptoms come on immediately.
In electric wire-men curious appearances may be produced by the volatili-
sation of fuses, especially when these are of copper, the patient's hand
being coated with a thin layer of the metal as if it were part of a bronze
statue. With low-voltage currents serious burns may result ; for
example, if a naked wire be allowed to lie in contact with the skin for
a few minutes in the operation of electrolysis a white, apparently dead,
area is produced at the point of contact ; part of this recovers, but much
of it will necrose. Radium gives rise to a burn of varying depth,
which is painful and slow to heal.

SYMPTOMS. The local phenomena of burns are usually de-
scribed under six headings or degrees as originally proposed by Dupuytren.
The first degree is caused by the transient action of a flame, or by a
body below 212 F., and is marked by redness of the skin, followed by
some swelling and pain, and subsequently by desquamation. The
second degree is caused by a more prolonged action of a flame, by boiling



BURNS AND SCALDS 175

water, or by solids at 212 F. ; and in this case the Malpighian layer of
the skin is disorganised, and inflammation, as shown by erythema and
the formation of bullae, follows. The third degree is reached when one
of the foregoing causes has acted for a longer period, or when the burn
is caused by red-hot metal, boiling salt water, or oil. Here there is
destruction of the epidermis, the Malpighian layer, and the papillae of
the skin, the result being that there is erythema, the formation of bullae
and superficial dry eschars ; the slough separates in about a week. In
the fourth degree the whole thickness of the skin and part of the sub-
cutaneous tissue are destroyed ; there is a black eschar with a white
circle around it, and a zone of redness beyond that. There is less pain
in this form of burn, but the healing is slow. In the fifth degree, not
only the skin, but the subcutaneous tissue and portions of the muscles
are completely destroyed ; it is caused by the long-continued action of
flame or red-hot metals, or chemical substances such as arsenious paste,
caustic potash, etc. ; a dry slough is formed, around which are seen the
various minor degrees of burns, from sloughing of part of the skin near
the eschar to simple erythema at a distance. In this form of burn joints
are frequently opened, especially as the slough separates, and conse-
quently very serious results may ensue. The sixth degree of burn is
that in which all the tissues of the limb are charred, and there is
complete destruction of the part subjected to the heat.

A later phenomenon in burns is the occurrence of a certain amount
of inflammation around the burnt area, due directly to the action of the
heat ; besides this, there may be septic infection with severe local and
general results if the parts have not been rendered aseptic. Later still
there is the separation of the slough, granulation, and healing.

The eonstitutional phenomena are divided into three stages, which
need only be alluded to. The first stage lasts for forty-eight hours, and
is marked by congestion of the parts in the neighbourhood of the burn,
and great pain ; besides this, there may be congestions of internal
organs. Thus, for example, when the burn is situated over the thorax,
the pleura or the lungs may become congested ; when it is over the skull,
the meninges may be similarly affected, and so on. During this stage
also there are other serious dangers for instance, shock, delirium, con-
vulsions, asphyxia from carbonic acid or carbonic oxide, or death with
symptoms of poisoning attributed to absorption of the partly broken-up
products of the burnt tissues. The second stage of burns lasts from the
second to the sixth or eighth day, and is termed the inflammatory period ;
this is marked by inflammation of the part, with sloughing of the dead
tissues, and a tendency also to inflammation of internal organs ; for
example, a burn over the head may be accompanied by inflammation
of the brain, a burn over the thorax by inflammation of the pleura or
the lungs. It is during this stage also that a peculiar phenomenon fre-
quently noticed in burns namely, inflammation and, in some cases,



176 WOUNDS

ulceration of the duodenum is observed. This occurs at the point where
the contents of the bile duct impinge on the intestinal mucous membrane,
and is possibly due, as was suggested by Dr. William Hunter, to the
excretion, with the bile, of irritating products resulting from an im-
perfect carbonisation of the tissues. In other cases haematuria or haemo-
globinuria occurs. The third stage begins when the slough separates, and
is mainly occupied by the healing process. Towards the end of the
second, and in the early part of the third stage, the patient is liable to
various general septic diseases and also to local septic troubles due to
the position of the burn ; for example, when this is situated over a cavity
such as a joint or the pleura, either may be opened as the slough separates,
and violent septic arthritis or pleurisy may follow.

The Causes of Death after Burns depend mainly on the extent, but
partly also on the depth, of the burn and the region of the body affected.
An extensive superficial burn is more dangerous than a limited but deep
one, whilst a burn over the head or the thorax is far more serious than
a more extensive one on an extremity. The causes of death after burns
are (i) shock, (2) collapse, (3) poisoning from absorption of partially
broken-down organic products at the seat of the injury, (4) congestion of
various internal organs, (5) inflammation of these organs, (6) intestinal
ulceration, (7) various septic diseases, particularly erysipelas, septicaemia
and pyaemia, and (8) exhaustion. In burns in particular situations of
course there are special dangers ; for example, in scalds of the throat
there is the danger of oedema glottidis and death by suffocation. When
the patient has been burnt in an explosion in a mine or in a burning
house there may be symptoms due to asphyxia or carbonic-oxide
poisoning.

TREATMENT. The treatment may be described under four heads
namely, the treatment of the first degree, that of the second, that of the
third and fourth degrees, and, lastly, that of the last two degrees. It is
also important to consider both local and general treatment.

General Treatment. The general treatment will depend largely
upon the extent and result of the burn. When a patient comes under
observation suffering from severe shock, the various measures appropriate
for the treatment of that condition (see p. 120) must be employed.

During the early stage also, apart from shock, it may be necessary to
counteract carbonic-oxide poisoning, which is indicated mainly by the
presence of dyspnoea, while the mucous membranes are of a cherry-red
colour and the pulse is slow. A drop of blood from a needle-puncture
shows marked deviation in colour from normal blood : it is of the same
bright cherry-red as the mucous membranes. This condition is due to
the carbonic oxide entering into combination with the haemoglobin, and
preventing the corpuscles from fulfilling their functions as carriers of
oxygen.

Carbonic-oxide poisoning must be treated by free stimulation, com-



BURNS AND SCALDS 177

bined with efforts to promote the oxygenation of the blood. Most
benefit will be obtained from the inhalation of oxygen ; and until this can
be obtained, artificial respiration by Sylvester's method must be carried
out if the breathing shows any tendency to flag. If a cylinder of oxygen
can be obtained, one end of an indiarubber tube should be attached to it
and the other to the mouthpiece of an ordinary Clover's inhaler, a glass
funnel, or a piece of brown paper folded into a cone ; the oxygen is then
turned on and made to pour over the patient's nose and mouth. The
mouthpiece should be removed every ten minutes or a quarter of an
hour for a minute or two, but the inhalation must be kept up for twelve
to twenty-four hours, until, in fact, a sufficient number of new blood-
corpuscles have been formed to act as carriers of oxygen. Transfusion
of blood has been suggested, but it seems that the blood-corpuscles thus
introduced do not retain their vitality for any length of tune, and act
only very temporarily, if at all, as carriers of oxygen to the tissues. As
a stimulant, caffeine given subcutaneously in doses of one grain or more,
with an equal quantity of salicylate of soda, and repeated in three or four
hours, is of use ; brandy will also be called for.

If symptoms of internal congestion or inflammation set in after the
patient recovers from the shock, the treatment must be conducted
partly on the lines indicated for acute inflammation and partly on those
appropriate to the organ affected. During the stages of sloughing and
convalescence, it is necessary to support the patient's strength by the
administration of a nutritious diet and the use of stimulants and tonics.
Blaud's pill (ten grains three times a day) or tinct. ferri perchlor. (ten
to fifteen minims three times a day) may be given ; quinine (three grains
thrice daily) is also of value.

Local Treatment. The local treatment may be considered in
connection with the various degrees of burn. In the First Degree the
erythema which occurs from radiant heat requires little treatment.
The chief trouble complained of is the sensation of heat and burning in
the part,, and the use of some soothing application, such as cold cream
or glycerine, which also acts by protecting the surface from contact
with the air, will often relieve it ; if not, lead or lead and opium
lotion (see p. 9) will be efficacious.

In the Second Degree, blisters should be punctured at the most
dependent spot, and their contents let out. The epidermis should
not be clipped away, and the incision should be just large enough to
allow the fluid to escape ; if the blister be opened freely the epi-
dermis is apt to peel off, exposing the papillary layer of the skin,
causing a good deal of pain, and retarding the healing. When the
injury has not gone beyond the formation of blisters, it is unneces-
sary to use antiseptic lotions, because the denudation of the papillary
layer does not entail any serious risk of sepsis ; it is best to apply an
antiseptic ointment over the blisters after they have been pricked.



178 WOUNDS

Eucalyptus ointment is an excellent application, but half-strength boric
ointment also acts well.

In the Third and Fourth Degrees, when there is partial or entire de-
struction of the whole thickness of the skin or of the deeper tissues, great
care must be taken to keep the parts aseptic, because the patient's
greatest risks are connected with sepsis after recovery from the shock and
for the first week or two afterwards. How best to secure asepsis is a
question of considerable difficulty, for it must be remembered that burnt
parts absorb fluids with extraordinary rapidity, and this is especially the
case with regard to carbolic acid. Hence, if this drug be freely used as a
disinfectant in burns, grave symptoms of carbolic poisoning, possibly
ending in the death of the patient, may result. Therefore the strong
mixture should not be used for the wound, and reliance must be placed
on i in 1000 sublimate solution. The undamaged skin around the burnt
area may be safely cleansed with strong mixture.

Since the heat itself has disinfected the part, it is not necessary to
employ disinfectants with the thoroughness required in operations, should
the burnt area have escaped subsequent soiling, as may be the case
when the patient is seen soon after the accident. Absence of infection may
be expected when the burnt part has not been covered with clothes ; when,
however, clothes have been pulled over the part in removing them, great
care must be employed in disinfection. As the patient is suffering from
shock and as the manipulations necessary for disinfection are very painful,
additional shock will be avoided if a general anaesthetic be administered.
Therefore it will often be better to apply some simple dressing such as
ung. eucalypti in the first instance, and to administer a full dose of
morphine, and so to allow the patient to rally from the shock. He is
then put under an anaesthetic, the skin around is purified carefully with
strong mixture, and then it and the burnt area are washed thoroughly
with a i in 1000 sublimate solution, which is subsequently removed by
douching with sterilised saline solution.

The best dressing is cyanide gauze rinsed out in a i in 8000 sublimate
solution, and salicylic wool. The dressing should be left undisturbed
for two or three days if the temperature remain normal and the patient
be comfortable ; indeed, should there be no evidence of sepsis after two
or three days, the dressings may be left on for a week or even
longer, any scabs which form being soaked off at each dressing. The
advantage of this dressing is that it keeps the part aseptic and also
allows the discharge to dry on the surface ; a reference to Chap. IV. will
show that one of the most important points in the treatment of gangrene
is to promote drying of the part. When the slough begins to separate
(sometimes it does not do so, but becomes organised in the same way as
blood-clot) and the parts around are granulating well, eucalyptus or boric
ointment may be substituted. When the slough has separated, the wound
must be treated as a healing ulcer (see p. 51), and, if it be of any size, the



BURNS AND SCALDS 179

sooner it is skin-grafted the better (see p. 54). When the slough is
unduly slow in separating boric fomentations will hasten the process.

Picric acid is much used for superficial burns, as it is said to allay the
intense pain effectually. It may be employed either as a saturated
watery solution, painted upon the burnt area with a camel's-hair brush
or applied on butter-muslin, or as an ointment containing one drachm
of the acid in an ounce of vaseline. The drug is not without its dangers,
as toxic symptoms e.g. a rash, pyrexia, and greenish-red urine have
followed its use. The acid coagulates the albuminous fluid oozing from
the sore, and forms a protective layer over the exposed nerve-endings
in the skin. The application should be made once or twice daily,
according to the size of the burn and the amount of discharge from it.
We have found it useful in superficial burns ; for the more severe ones
we prefer the method just described.

It is necessary to warn the practitioner against certain commonly re-
commended applications for burns. Carron oil (a mixture of linseed oil
and lime water), for example, is a filthy application; poultices or water
dressings and dusting with flour are equally bad. The wound must be
treated aseptically as far as possible, as sepsis is the primary cause of
death in a large number of deep burns.

Should the case come under observation with a foul sloughing wound,
or should the attempt at disinfection fail, and the wound become septic,
the best method of treatment probably is the water bath. If the trunk
be affected and the burn be large, very painful, or accompanied by con-
stitutional disturbance, the patient is placed in a bath, the water (at a
temperature of 100 F.) containing a small quantity of an antiseptic, such
as Condy's fluid or sanitas, and being changed every three or four hours.
The patient should be taken out of the bath at night, and a wet boric lint
dressing applied ; this consists of boric lint boiled in a saturated solution
of boric acid and applied warm and wet ; outside this is placed a larger
piece of sterilised jaconet or gutta-percha tissue. Next morning the
patient is again placed in the water bath, and kept in till evening, and
this is continued until the sloughs have separated and the inflammation
has subsided. Then boric dressings, antiseptic ointments or protective
and boric lint, applied as for healing ulcers (see p. 51), should be sub-
stituted. When the extremities are affected, special baths (see p. 34)
will be required.

If the burn be of any size, skin-grafting should be employed (see p. 54)
as soon as the sloughs have separated and the wound has begun to
granulate ; this is especially necessary in burns, because the sores result-
ing from them have a peculiar tendency to contract. Sores left by burns
heal much more slowly than wounds made by the knife, probably because
the heat not only destroys the vitality of the part immediately acted
upon, but also impairs that of the tissues around, so that in the
early stages the vital processes in them are not so active as usual.



i8o WOUNDS

Therefore there is more granulation tissue formed, and greater subse-
quent contraction.

When the slough is situated over a joint or a serous cavity, and there
is reason to fear that either may be opened when the slough separates,
special care must be taken in the antiseptic management of the case,
because, should the part become septic, there may be acute suppuration
of the articular or the serous cavity.

In the Fifth and Sixth Degrees the treatment is only of importance
when the burn affects the extremities ; if it be situated elsewhere, the
patient usually dies at once. Should a burn of these degrees occur upon
the skull or part of the trunk, however, and should the patient survive,
the aim of the surgeon must be to render and keep the part aseptic, to
support the patient's strength, and to wait until the slough separates ;
then, if no vital part be involved, the defect will be gradually filled up with
granulations, and a time will come when skin-grafting can be employed.
In the extremities, however, the question of primary amputation arises,
when the tissues down to and including the bone are completely charred,
or when only the fifth degree is reached, and the tissues are destroyed over
a large area. This question must be answered in the affirmative when
the extremity is hopelessly destroyed ; the only points for discussion are
as to when and where the amputation should be performed. As a rule
it is best to wait until the shock has passed off, for if amputation be
performed before this, as is frequently the case, the shock is apt to be
much increased, and to bring about a fatal result. In the majority of
cases it is quite safe to wait for from twelve to twenty-four hours, if the
part be roughly disinfected and wrapped up in an antiseptic dressing ;
when the shock has been recovered from, at any rate partly, amputation
may be proceeded with, taking care to employ all the measures calculated
to prevent or minimise shock (see p. 118). Spinal analgesia here finds
one of its most useful applications. In determining the level at which
to amputate it must be remembered that it is not necessary to go far
above the actually charred tissue ; there is certainly no need to go above
the region of the erythema. If the part be kept aseptic this congestion
will subside without leading to any trouble during the healing of the
stump ; special attention must be devoted to the purification of the skin
in the region of the amputation.



EFFECTS OF INTENSE COLD.

The local effects of intense cold in some respects resemble those
of heat. The parts chiefly affected are those most distant from the
heart, such as the toes and the fingers (especially the great toe and the
little finger), the nose and the ears. Moist cold is more likely to do harm
than dry, and when there is wind, frostbite is much more likely to occur



EFFECTS OF INTENSE COLD 181

than when the atmosphere is still. The effect of cold is to cause great
local contraction of the vessels, so that the part at first becomes livid and
ultimately white. On the cessation of the cold, reaction takes place ; the
vessels become greatly dilated, and stasis is apt to occur and may end in
thrombosis if the reaction be too severe. When death results from cold,
the most common appearance met with post-mortem is thrombosis of the
vessels of the internal organs. Various other local changes are described
as the result of cold, the most important being degeneration or inflamma-
tion of nerves ; these may possibly have something to do with the peculiarly
languid ulcerations which affect parts that have been exposed to severe
cold. The changes probably result from thrombosis of the nutrient
vessels of the nerves.

The clinical effects of cold may be divided into three degrees. The
first degree corresponds to the first degree of burns : it consists simply of
erythema of the part, and is a reactionary phenomenon : the second degree
corresponds to the second degree of burns, at any rate to a great extent ;
and the third degree, or frost-bite proper, may be taken to represent the
remaining degrees of burns.

Chilblains. The first effect of cold is erythema. The skin becomes
of a wine-red or violet colour, which disappears on pressure ; the cutaneous
circulation is slow and there is swelling of the skin and subcutaneous
tissues, with a feeling of numbness in the part. In addition to this
feeling of numbness there is much itching and pricking, if heat be applied
too suddenly. This condition generally disappears in a few days ; if,
however, the exposure to cold, followed by the application of heat, be
repeated, it may lead to the condition known as chilblain which, if not
properly treated, may become cracked and ulcerated.

Ulcers. The second degree of cold leads to the formation of bullae
containing clear or bloody fluid, and these may be followed rapidly by
atonic ulcers which show little tendency to heal ; there is also smarting
in the part. When the condition is yet more chronic we have what are
practically ulcerating chilblains, the skin being swollen, cedematous,
cracked, and marked by shallow fissures which yield a yellow or brownish
liquid, very prone to dry up. These cracks enlarge and form obstinate
ulcers.

Frostbite. The third degree is that in which the skin and a variable
amount of the deeper tissues die ; the skin becomes livid and mottled,
and numerous large bullae, containing rusty-coloured serum, are formed,
or else sloughing takes place. If warmth be applied too quickly, the
condition results in severe inflammation, followed by gangrene. The
gangrene spreads slowly, and there is an imperfect and temporary line
of demarcation much the same as in the senile form ; if opportunity be
afforded, the dead part dries up, but the gangrene is not typically a dry
one from the first. In other cases the sloughing is quite superficial, but
the frostbite is followed by permanent malnutrition, with anaesthesia,



182 WOUNDS

analgesia, or even atrophy of the limb, or by the formation of perforating
ulcers.

TREATMENT. Prophylactic. The treatment of the effects of
cold is partly prophylactic and partly curative. As a measure of pro-
phylaxis, persons who must necessarily be exposed to severe cold should
take large quantities of fatty food. The clothing should be thick and
woollen, it should not be tight-fitting, and the feet especially should be
kept warm ; the body, particularly the exposed parts, should be oiled
in order to prevent evaporation, and when the patient is exposed to
intense cold, he should keep actively moving, and must not yield to the
desire to rest or sleep, which is often very great.



Online LibraryWilliam Watson CheyneA manual of surgical treatment (Volume 1) → online text (page 21 of 61)