The etiology and incidence of thermal burns

New Series VOL. I, No. I

American Journal of Surgery

T H E ETIOLOGY. AND I N C I D E N C E OF T H E R M A L BURNS GEORGE T. PACK, B.S., M.D. Lecturer in M i n o r Surgery, T h e SchooI of Medicine, T h e University of A I a b a m a UNIVERSITY~ ALABAMA

HE purpose of this communication is to consider the causes and occurrences of burns and scalds, to emphasize the neglect of certain precautionary measures, and to stimulate increased interest in the prophylaxis and reduction of the morbidity and mortality rate of burns. "A burn is an iniury inflicted on the body by a degree of heat higher than is compatible with heaIthy action in the part affected." The types of thermal trauma are two: burns that are produced by dry heat, and scalds by moist heat. The skin is the most common seat of caIoric injuries, which are accordingIy termed dermatitis caIorica, of which there are two divisions, dermatitis ambustionis (burn) and dermatitis congeIationis (frostbite). The progress of civiIization and the improvements in the arts and sciences have greatly multiplied the frequency and severity of burns. With the replacement of gas by electricity for illuminating purposes, the percentage of burns from gas has steadily diminished. About 45% of deaths from burns occur from birth through the fifth year. The frequency of burns and scaIds in chiIdren can often be attributed to the careIessness of parents and servants, and to the natural t e m e r i t y and incautiousness of children. Severe and fataI scaIds have been produced by pIacing chiIdren and infants in baths supposed to have been properIy tempered. In the confusion, concomitant with a convuIsion in infants, or by the hot bath treatment for asphyxia neonatorum, the overheated water has been responsibIe for serious ioss of skin. ScaIds frequentIy occur by smaII chiIdren failing into open tubs of hot water. KettIes containing boiIing water, soup, or coffee, are only too frequently upset, spilling their

contents on the upturned faces of IittIe chiIdren. Burns are more common and severe in instances where tactile sensations are subnormaI or absent, as in tabes dorsaIis, acute aIcohoIism, coma of various types, epilepsy and paralyses. The injudicious use of hot water bottIes applied to the bodies of anesthetized individuals for the purpose of inducing a better circulation occasionaIIy result in a burn, because pain, "the warning sentinel of injury" is lacking. A paraIyzed Iimb is burned or scaIded at comparativeIy Iow temperatures. Every surgeon has encountered burns of epileptics, and patient and doctor aIike are happily surprised to note a disappearance or lessened frequency of the epiieptic attacks. This peculiar phenomenon was known by physicians of an earIy date, who heroicaIIy and unsuccessfully attempted to cure epilepsy by burning the patient. Burns kilI more femaIes than males. Statistics for a Iong period of years show that three out of five deaths from burns are of women and girls. 1 During the first three years of Iife, although they are simi[ariy dressed, more boys than girls die of burns, probably because the venturesome spirit of the boy exposes him to greater danger. ' Figures of the MetropoIitan Life Insurance Company covering a period of over twenty years show that in the fourth year of life the relatively high death rate of females begins. "The margin increases from five to nine years where more than twice as many girls as boys die of this cause, and there is a more or Iess plonounced excess in the death rate for females untiI the age of thirty-five is reached. It is not until the age of thirtyfive is reached, where very Iarge numbers of men are engaged in industries subjecting them to the hazard of burns and scaIds

T

2I

I922 I92I I920 1919 19182 19173 1916 1915 1914 I913 1912 191I 191o

4935 4839 4567 4182

5021

5962 5329 6645 6409 6638 6830 5726 4804

189I 181o

2072

2156

2105 2192

2688 293o 2976 2579

2242 2718

2456

3506 3087 3927 372I 3708 3854 3147 2699 2829 2779 2767 2676 2372

6.4 6.o 7.6 7-5 8.2 9.1 8.0 7.2 7.6 7.8 8.0 7.7 7.8 177 15o

I83

251 221 273 251 239 302 243 194 2o6 208

I Yr.

der Un2 Yrs.

65I 624 765 773 748 8Ol 656 595 642! 634; 582 53 I 53o 558 447[ 508

648 582 652 686 688 720 660 576 547 534

I Yr.

Includes tile D. C. Age details excludes 21 soldier deaths, data not available. Age detail excIudes i soldier death, data not avaiIable.

78,5 73.4 70.8 67.5 67,2 65.5 63.5 63.2 58.3

82.2 82.2 8I.I

85.3

Per Cent of Rate p the Esti100, OOI mated PopEstiArea uIation of Femated and Continental Total Males males PopuIa Year U. S. in the tion Registration (Both Area Sexes)

TABLE I

4 Yrs.

639 589 694 656 7IO 660 604 488 524 55 ° 514 530 432

44 ° 430 539 547 482 462 443 339 394 427 367 333 298

771 645 853 828 809 734 614 489 553 531 504 441 476

326 327 466 398 4II 434 294 267 274 256 258 26i 229

433 365 472 434 480 556 466 398 352 386 387 330 352

370 357 45I 421 462 457 412 3o8 355 346 353 322 318

321 275 372 364 406 403 305 291 294 268 295 306 266

324 255 312 299 334 368 314 235 251 26I 262 260 2O5

222 212

249 223 2ii 244

283!

25o 297J 278i 335! 3281

295~

277 259 282 25 I 302 334 266 219 223 208 233 195 192

2o

29 20 18 24 ii 17 9 II

I7I I36 128 142 97 95 80 78

36 17 24 27 I71

I69 118 I7o 176

3 8 13 8 6 7 4 7 3 4 3 5 3

8 5

II

3

14

14 63 6 3

IO I2

8 7

Deaths I oo at Un5-9 lO-19 2o-29 3o-39 40-49 50-59 60-69 70-79 80-89 90-99 Years Yrs. Yrs. Yrs. Yrs. Yrs. Yrs. Y r s . Yrs. Yrs. Yrs. and k n o w n • over Age

The Registration Area I

3 Yrs.

Age (Both Sexes)

DEATHS FROM BURNS (CONFLAGRATION EXCEPTED)

g

7

NewSeriesVOL.I. No.

P a c k - - T h e r m a l Burns

I

that as many males die from this cause as do females. In later Iife when fewer men are subject to these risks, women again experience a much higher death rate. Burns of women occur at home and arise usually from their househoId duties. Female attire is an important factor in increasing the hazard." 1 Burns are more common in winter than in summer. Burns stand fourth in numericaI importance among the causes of accidental death, being outranked only by automobile fatalities, fails, and drownings. A study of Table One, showing the number of deaths from burns, by sexand age, for the U. S. registration area for the years 191o to 1922 ,incIusive, wilI show the decline in the ratio of the number of deaths per IOO,OOO of population. T h e increasing number of yearly deaths can be partially attributed to the greater registration areas and the increase in population. TABLE

DEATH

FROM

INSURANCE

TABLE

III

RATES

PER

1I

t~URNS AND CONFLAGRATION

REGISTRATION

LIFE

AREA

AND

I N U . S.

METROPOLITAN

COMPANY.

AND

DEATH

FROM VARIOUS

100,000

KINDS OF BURNS, AREA,

I92I 4

INDUSTRIAL

Burns

Deaths

Death rate* per

Deaths

Death rate t per I00,000

I 6.4 6.o 7.6 7.5

6.3 6. I 6.6 8.1 8.I

Deaths

Conflagration

IO0,O00

U. S. D e a t h Reg. Area 1922 5,962 1921 5,329 I920 6,645 1919 6,409 M e t r o p o I i t a n L. I. Co. Industrial Dept. 9 I0 I923 1922 842 1921 I 892 1,06I 1920 I,OOI 1919

POPULATION

U. S. REGISTRATION

DEPARTMENT

Year

23

Unfortunately, statistics concerning burns include death by conflagration, although alI the deaths that occur in connection with burning buiIdings are by no means due to actual burns, but are often to asphyxiation, crushing, etc. ~ Of aII persons sick and unabIe to work in the various industries from o.3 % to o.9% are incapacitated on account of burns. An approximate mortality rate is hard to estimate, because so m a n y burned patients are ambulatory, but of hospital admissions, from 25% to 3o% of patients die as a result of their injuries. The number of yearly deaths from fire due to fireworks varies between twelve and forty individuals: these burns are produced by giant fire-cracker and powder explosions. 3 In the recent World War among the personneI of the U. S. Army, there were 6,I48 cases of ordinary burns with 113 deaths, and 1,325 cases of chemical burns (exclusive oft mustard gas) with 7 deaths. DEATHS

MORTALITY

A.... ioanJ....... 1of Surgery

928

[

I

1,042

I.O 1,2

977

I.I

I 7 79 IYI IO4

I.

.6 .9 .8

* D e a t h rate per lOO,OOO p o p u l a t i o n in U. S. D e a t h R e g i s t r a t i o n Area, t D e a t h rate p e r too,ooo policy holders in t h e M e t r o p o I i t a n L. I. Co., I n d u s t r i a l D e p a r t m e n t . :~ N o t available.

Conflagration .................. 928 Burrfs; (conflagration excepted). , 5,329 (a); M o l t e n m e t a l . . . . . . . . . . . . 14 (b) ; P l a y i n g with fire, m a t c h e s etc .................... 447 (c); Fall into fire . . . . . . . . . . . . ! 113 (d); Scalds . . . . . . . . . . . . . . . . . . 1,371 (e); O t h e r s . . . . . . . . . . . . . . . . . i 3,384 i

Death Rate per t oo,ooo PopuIati0n I,O

6.o

o.5 O.I

I. 5 3-8

* Less t h a n o n e - t e n t h of one p e r ioo,ooo p o p u l a t i o n .

The frequency of fatalities from burns occurring in civil life is generally underestimated. A tabIe is given to ilIustrate the rela,tive death rates from burns and appendicitis; showing that burns are not given enough consideration by medical press and medicai teacher. The decrease in the death rate of burns is not due to any radical betterment in therapeutic procedures, but rather to certain prophylactic

24

An'Jericall J . . . . .

1 of S u r g e r y

Pack--ThermaI

measures tbr which the medical profession has not been directly responsible. TABLE

IV

D E A T H RATES PIeR I 0 0 ~ 0 0 0 FOR BURNS AND A P P E N D I CITIS. U. S. R E G I S T R A T I O N A~REA

Death Rates per IOO,OOO U. S. Reg. Area

Year

1924 I923

Burns

Appendicitis

!

* 6.7 6.4 6.0 7.6 7.5 8.2 9.1 8.0

1

7.2

* I4.8 i4.2 I4.4 I3.4 Ii.8 I2.2 i2.6 i2.8 12.s i2.3 I2.I ii.6 i1.7

[ ]

I922

I92I t920 t919 t918 I917 I916 19I 5

i

1914 1913

7.6 7.8

I912

8.0

I9It

7.7

- -

* N o t avaiIabte.

A burn can be caused by any body that radiates much heat. ~ This is commonly due to proximity to, or direct contact with, flame or heated soIid bodies, superheated air, g a s explosions and inflammable liquids, such as benzine and turpentine. ScaIds are produced by the action of boiling water, or other liquids, superheated steam and molten metals. The difference in the effects of burns and scaIds is comparabIe to the distinction between roasting and boiling. The results of burns vary according to: I, the degree of temperature; 2, the nature of the exciting agent; and 3, its capacity for he,at absorption; the duration of contact; 5, the susceptibility of the part acted upon; and 6, the condition of the patient. Dry heat of I4o ° F. and upwards is capabIe of producing burns; scaIds by moist heat of Ia5 ° F. and higher. The higher the temperature of the burning agent, the more severe injury will result, other conditions being equal. Fluids, such as oiI, that boiI at higher temperature than water produce increas-

Burns

JULY, I926

ingly severe results. The thicker the fluid is, at the same temperature, the greater is therefore its capacity for heat. Moreover, this oleaginous fluid adheres Ionger, and evaporation being slower, the effect is naturally more severe. As the heat of solid bodies is usually greater than that attained by liquids, except metals in a state of fusion, the former may produce very deep burns; while Iiquids flowing over a large surface, cause more extensive though comparativeIy superficial Iesions. Solid substances as iron and steel, and the fixed oils (olive and Iinseed) cause more severe burns than aqueous materials. Fluids of the nature of alcohol and chloroform, produce only very superficial burns because of their voIatility. The relative capacity of the substance for heat does not always determine the intensity of the injury, although in many instances this' is true. For example, it is generally known that copper wilI occasion a more violent effect than iron, although the latter possesses a greater capacity for heat. This apparent paradox can be expIained on the assumption that some articIes are not only better heat conductors than others, but they cause a more decided destruction of tissue, due to their tenacious adherence to the surface. This factor is evident in burns by hot pitch. In such instances the adherence to the skin involves the tearing away of the superficiaI portions of the derma in the removal of the burning agent. The degree of inflammation is proportional to the length of contact of the burning agent, a short period favoring a mild injury and a Iong period even an incineration. Dense and thick skin (paIms, soles and buttocks) offer a greater resistance to heat than is offered by that of thinner, softer texture (neck, abdomen and axilla). AII the tissues are not equaIIy susceptible to heat destruction. The application of heat within the stomach at 65 ° C., within the colon at 68 ° C., and within the peritoneal cavity at 580 C. will cause vesication. The skin is more resistant than the

New Series VOL. I, No. I

Pack---Thermal

mucous membrane and the latter more than the peritoneum (Turck6). All individuals are not equalIy susceptihie or sensitive to heat. Thus, it is a common experience that one person can handle hot objects that wouId burn another; the difference here is not entireIy related to thickness of integument, or sensitiveness of the nerve endings for heat. Duke 7 has presented evidence that patients may be aIIergicaIIy sensitive to heat from any source--hot water, hot weather, hot drinks, heat of Iamp--and that these patients gave what he termed reflex-like reactions such as erythemia, pruritus, urticaria, .and angioneurotie edema. Practically alI of these patients had constantIy a subnormal temperature. They would undoubtedly burn easier than the normaI person. Metals in a state of fusion produce Iesions that are usually of a greater severity on account of the high temperature to which they have been raised. ~ Such burns are theoretically classed as scalds. But the Iesions cannot be easily distinguished from burns caused by solid bodies. The catastrophe of carbonization has frequentIy occurred in metaI foundries, where the workmen have accidentalIy pIaced their feet, or some other part of their bodies, in the course of the molten metal. In expIosions, the mechanical vioIence as weI1 as the burning, must be taken into account. Gun-powder explosions usualIy produce severe and deep burns. A brush burn is a variety of contused wound, known aIso as a friction burn. The injury is a doubIe one, caused by a wearing away of tissues, and by the heat generated by friction. It is produced in innumerable ways, as by a rapidIy revolving grindstone, the friction of a rope slipping through the hands, an involuntary slide down a steep incline, contact with the rapidly revolving leather belts of machinery, etc. Continued or prolonged exposure of

Burns

a . . . . . iean J . . . . . 1 of Surgery

25

the skin to artificial heat, produces an erythematous burn known as erythema ab igne (epbelis ignealis) or fire flowers. This appears as a mottling or marbIed appearance of the skin, occurring for the most part on old peopIe, who toast their legs at the fire. It is also frequently observed on the chin and cheeks of cooks, stokers, steeI miII and blast furnace empIoyees. SUMMARY

I. Burns and scalds merit especiaI consideration because the great majority of these iniuries are preventabIe. 2. The mortaIity rate of burns and scaIds is exceedingly high, as compared with other injuries of equaI frequency. 3. The therapeusis of these injuries in general u s e today has not appreciably bettered the prognostic outlook, if we judge from statisticaI records. 4. Because of the prevalence of burns and scalds in children of pre-schooI age, they should be particuIarly protected from the possibilities of thermaI accidents. 5. In their conduct of househoId duties, women too frequentIy are obIivious of the dangers to which their cIothing subiects them. I wish to express my thanks to Dr. Louis I. DubIin of the Metropolitan Life Insurance Company, and to Dr. William H. Davis of the Department of Commerce for the statistical data. REFERENCES

I. StatistleaI BuIIetin; MetropoIitan Life Insurance Company, October, I923. 2. DUBLIN, LOUIS I. PersonaI communication to the author. 3. Fourth of JuIy Injuries. J. A. Mr. A., Ivii, 736, August 26, 19II. 4. MORTALITY STATISTICS. D e p a r t m e n t of Commerce,

Bureau of the Census~ I92I, BuIIetln I52. 5. SHUH. All& Med. Zeitung, I864. 6. TURCK, F.' B. AM. JOUR. SURG., XXXVll, 129. 7- DUKE, W. W. PhysicaI AIIergy, d. A. M. A., lxxxiv, 736, March 7, 1925 • 9. POUmLET. Comptes Rendus, I836, p. 782.