id. 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
r