BURNS AND SCALDS  . A burn is the effect of dry heat applied to some part of the human body, a scald being the result of moist heat . Clinically there is no distinction between the two, and their classification and treatment are identical . In Dupuytren's classification, now most generally accepted, burns are divided into six classes according to the severest part of the lesion . Bums of the first degree are characterized by severe pain, redness of the skin, a certain amount of swelling that soon passes, and later exfoliation of the skin . Burns of the second degree show vesicles (small blisters) scattered over the inflamed area, and containing a clear, yellowish fluid . Beneath the vesicle the highly sensitive papillae of the skin are exposed . Burns of this degree leave no scar, but often produce a permanent discoloration . In burns of the third degree, there is a partial destruction of the true skin, leaving sloughs of a yellowish or black colour . The pain is at first intense, but passes off on about the second day to return again at the end of a week, when the sloughs separate, exposing the sensitive nerve filaments of the underlying skin . This results in a slightly depressed cicatrix, which happily, however, shows but slight tendency to contraction . Burns of the fourth degree, which follow the prolonged application of any form of intense heat, involve the total destruction of the true skin .

The pain is much less severe than in the preceding class, since the nerve endings have been totally destroyed . The results, however, are far more serious, and the healing

process takes place only very slowly on account of the destruction of the skin glands . As a result, deep puckered scars are formed, which show great tendency to contract, and where these are situated on face, neck or joints the resulting deformity and loss of function may be extremely serious . In burns of the fifth degree the underlying muscles are more or less destroyed, and in those of the sixth the bones are also charred . Examples of the last two classes are mainly provided by epileptics who fall into a fire during a fit . The clinical history of a severe burn can be divided into three periods . The first period lasts from 36 to 48 hours, during which time the patient lies in a condition of profound shock, and consequently feels little or no pain . If death results from shock, coma first supervenes, which deepens steadily until the end comes . The second period begins when the effects of shock pass, and continues until the slough separates, this usually taking from seven to fourteen days . Considerable fever is present, and the tendency to every kind of complication is very great . Bronchitis, pneumonia, pleurisy, meningitis, intestinal catarrh, and even ulceration of the duodenum, have all been recorded . Hence both nursing and medical attendance must be very close during this time .

It is probable that these complications are all the result of septic infection and absorption, and since the

modern antiseptic treatment of burns they have become much less common . The third period is prolonged until recovery takes place . Death may result from septic absorption, or from the wound becoming infected with some organism, as tetanus, erysipelas, &c . The prognosis depends chiefly on the extent of skin involved, death almost invariably resulting when one-third of the total area of the body is affected, however superficially . Of secondary but still grave importance is the position of the burn, that over a serous cavity making the future more doubtful than one on a limb . Also it must be remembered that children very easily succumb to shock . In treating a patient the condition of shock must be attended to first, since from it arises the primary danger . The sufferer must be wrapped immediately in hot blankets, and brandy given by the mouth or in an enema, while ether can be injected hypodermically . If the pulse is very bad a saline infusion must be administered . The clothes can then be removed and the burnt surfaces thoroughly cleansed with a very mild antiseptic, a weak solution of lysol acting very well . If there are blisters these must be opened and the contained effusion allowed to escape . Some surgeons leave them at this stage, but others prefer to remove the raised epithelium .

When thoroughly cleansed, the wound is irrigated with sterilized saline solution and a dressing subsequently applied . For the more superficial lesions by far the best results are obtained from the application of

gauze soaked in picric acid solution and lightly wrung out, being covered with a large antiseptic wool pad and kept in position by a bandage . Picric acid 12 drams, absolute alcohol 3 oz., and distilled water 40 oz., make a good lotion . All being well, this need only be changed about twice a week . The various kinds of oil once so greatly advocated in treating burns are now largely abandoned since they have no antiseptic properties . The deeper burns can only be attended to by a surgeon, whose aim will be first to bring septic absorption to a minimum, and later to hasten the healing process . Skin grafting has great value after extensive burns, not because it hastens healing, which it probably does not do, but because it has a marked influence in lessening cicatricial contraction . When a limb is hopelessly charred, amputation is the only course .