, BURNS AND SCALDS Reflected heat as well as flames, hot solids, fluids and gases may have destructive action upon the tissues of the body, in most cases the skin and subcutaneous tissue are affected.
The first degree of burn (combustion mythematosa) is shown in the redness and swelling of the skin (insolation, scalding with water at 50° C.). The symptoms disappear after a few clays, leaving increased pigmenta tion of the skin.
Treatment.—Mild ointments.
The second degree (combustio bullo6a) shows blisters upon the skin besides the symptoms of the first degree which consist of a collection of liquid between the epidermis and corium. Severe pain is present, which increases when the corium is exposed after the blisters have broken or when the pieces of epidermis have been removed.
Treatment.—Opening the blisters, leaving, however, the epidermis for protection; soiled pieces of epidermis are removed; washing with sterile salt solution (.7 per cent.), or at most with some hydrogen peroxide (1 to 2 per cent.).
Small exposed parts of the corium are covered with sterile oint ments (or with the inner membrane of an egg which has been taken out under aseptic precautions).
Ointments: lime water with olive oil, equal parts, and dermatol 10 per cent. Bardeleben's bismuth bandage or sterile powder dressings or talcum powder with 5 per cent. zinc oxide are useful.
In the third degree the skin is escharotic and the subcutaneous tissue is also affected (combustio escharotica). The slough demar cates from its surroundings during the process of healing and is east off, and the consequent granulating surfaces heal, leaving large sears. If they should be extensive, these burns will cause severe general symptoms, rise of temperature, symptoms of poisoning 1,vomiting, convulsions), disturbances of consciousness (delirium, coma), lowering of the blood-pressure (small pulse, heart weakness). Large burns (more than one-third of the surface of the body) usually cause death during the first twenty-four hours with the above described symptoms and small children are especially sensitive. Even after the first symp toms have abated life is still threatened by nephritis, coma, thrombosis (duodenal ulcers).
The primary treatment must he symptomatic except for the tem porary aseptic dressing: excitants, heart tonics, administration of liquids as hypodermoelysis or micro-clysmat a (see Peritonitis).
After the primary dangers from shock, heart failure and nephritis have passed we try to prevent the extensive scars. As these large granu lating surfaces rarely remain free from infection (pyocyaneus), we must refrain from extensive grafting upon the granulating tissues. We may
considerably shorten the process of granulation by grafts, according to Thiersch, thus forming new islets from which cpidermization advances.
The granulations arc cleansed as much as possible with compresses moistened with salt solution and for some days they are brought to the level of the skin by the application of compressive bandages. Upon the granulations we transplant, without scraping, long narrow Thiersch grafts; to cover these we have found perforated pieces of protective silk soaked in oil to be best. Large and wide Thiersch grafts do not take hold well on account of the pus collecting underneath. Smaller Thierseh grafts also should be applied at several sessions. Narcosis is hardly necessary when we use local anmesthesia of the respective nerves, and a repeated light etherization is less dangerous than one long deep narcosis.
Large transplantations of skin should be left till later (Fig. 149), when scars have formed in place of the large granulating masses, be cause we can control the result much better with a clean freshly-made wound.
When we treat large granulating surfaces with ointments we must always remember to change the remedy from time to time during the healing, ell takes many months, to avoid cumulative action. We were able to observe in one case of long-continued treatment with der mato] ointment a bismuth intoxication, which showed in affections of the mucous membranes, deposits of the metal on the teeth, and bismuth could be shown in the urine similar to an intoxication with mercury.
Freezing (congeiatio) (see Galewsky, vol. iv) usually affects the most peripheral parts of the body of children (schoo: children). We must here state that for a congelation a temperat ure at or below the freezing point is by no means necessary in weak children. A stay for any length of time in places which arc not heated (10° to 12° C.), in boarding schools for instance, suffices to produce chilblains.
The different degrees of congelation are the same as in burns.
The treatment has to restore first of all in congelations of the first degree the tone of the blood-vessels (chilblains, perniones), hot baths, hot and cold baths alternately, massage, hot packs. For their prevention all constrictions should be avoided (big shoes, mittens). Local treatment consists in the application of ointments or astringents.