All bulke or blebs should be pricked at their most dependent point to evacuate the contents, which are always full of micro-organisms; some authorities for this reason snip away their epithelial envelopes, whilst others prefer to preserve these as a covering for the inflamed skin beneath them.
The experience of recent years has proved that a good routine antiseptic dressing for burns and scalds of every degree of severity is a solution of Picric Acid, i part in roo water; this is practically a saturated solution, but some prefer to user in 200, with 1 o per cent. rectified spirit. Boiled or sterilised lint or cotton-wool soaked in the solution should be placed in contact with the burned part, and covered with a layer of cotton-wool, the strips being so applied that they can be removed with the least degree of difficulty or pain to the patient. No impervious dressing should be applied over this, and on every third day the application can be removed and fresh lint applied. A r to 2 per cent. ointment is sometimes used in stead of the aqueous solution, and Picric Acid Wool is also supplied ready for use.
The experience of the late war has shown the value of Ambrine, a mixture of hard and soft paraffin. This is melted and either sprayed on the part from a special sprayer, or painted on with a soft camel's-hair brush. It prevents evaporation from the surface, prevents dressings sticking to the raw surface, and promotes healing. It is especially suited to burns or scalds in children, and can be used for burns of any degree of intensity.
Loose dead and charred fragments may be removed by scissors during the first dressing, and at subsequent dressings the dead skin can be re moved in a similar manner without employing any traction or force.
The danger in all cases after the patient has been tided over the grave period of shock is sepsis from the absorption of toxic products contained in the charred tissue, or produced by the multiplication of extraneous micro-organisms; hence the necessity of the use of sterilised dressings and thorough cleansing with mild antiseptic solutions between the times of dressing. The indiscriminate use of strong antiseptics like II yd. Perchlor., Iodoform, Carbolic Acid, &c., is to be condemned where the burned surface is extensive, since poisoning from their absorption is liable to occur, and, moreover, they tend to retard the separation of the sloughs. To facilitate the removal of the latter nothing is better than hot Boric Acid fomenta tions; where there is much moist discharge Boric Acid may be freely sprinkled in fine powder, or Iodoform Gauze may be employed in thick layers. The dressing, which by its absorptive and antiseptic qualities renders frequent changes unnecessary, is always to be preferred, hence ointments as a rule are to be avoided, though dressings of these are more easily removed. The long list of these preparations still recommended
and used should be condemned ; most of them contain antiseptic substances insoluble in their fatty basis, and while the heat of the body liquefies the latter, it soaks into the superimposed dressing, forming a casing which keeps the injured tissues bathed in their unhealthy secretion, and the crude insoluble antiseptic acts as an irritant.
After all sloughs have separated or been cautiously removed, the granu lating wound is to be treated upon general surgical principles, and where this is extensive skin grafting by Thiersch's method should he resorted to early in order to hasten healing, diminish the danger of septic absorp tion, and minimise the risks of future deformities. Flabby granulations may be destroyed by solid Copper Sulphate, or by any stimulating lotion, by mild bandage pressure, or by the application of perforated green pro tective dressing. The complication or sequela of duodenal ulcer must be watched for and treated accordingly.
Care and attention must be bestowed during the healing process of deep burns when these occur in the vicinity of joints so as to avoid the deformities liable to occur as the tissue slowly contracts. In the face also this is to be carefully watched, and continual massage applied, skin grafting, and the division of bands, followed by stretching of the parts and other plastic operations, may be necessary. When the constituents of a limb have been hopelessly charred the only resource may be amputa tion after the shock has been treated.
Burns produced by electricity, X rays and lightning are to be treated upon the above principles; the milder X-ray dermatitis may be soothed by the use of any of the emollient ointments suitable for acute eczema, but the slowly separating sloughs of the deeper type of the accident must be treated like burns of the fourth degree, and will usually require skin grafting.
Burns of the conjunctiva are generally the result of sparks of hot metal or caustics; the best treatment will consist in the introduction of Atropine and the repeated flushing of the conjunctival sac with warmed Boric Acid solution applied by means of the eye-douche. When much inflammatory swelling and (edema are present the external canthus may require incision, and the greatest attention should be paid in order to prevent adhesion of the eyelid to the globe. I ritis and corneal ulceration must be treated by suitable agents and Eserine instilled occasionally. When the lids or adjoining portion of the face have been involved the resulting cicatricial ectropion can only be remedied by a plastic operation, the best of which is that devised by Wolfe, who inserts a skin graft from the inner side of the arm after a free incision exposing a considerable raw surface beyond the free margin of the lid.