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I E V E N L A N D ASSOCIATION of CHEMlSTRY TEACRERS
The Modern Treatment of Burns' ROBERT HENRY ALDRICH Harvard Medical School, Boston, Massachusetts
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T THE present time the subject of bums is in a state of flux. Experience of the British, stimuated by the war efforts, has indicated that no one form of treatment has been accepted as a solution of the problems presented by the burned patient. Even before the war began in this country, bums assumed a leading role in diseases. In 1940 they killed more people in this country than were killed by bombs in England during the same year. According to figures published by the National Safety Council in 1941, burns killed 23 per cent of all children dying of accidental death under the age of five. From five to Bteen, burns killed 12 per cent of those dying violent deaths, and from fifteen years on, burns took a toll of 6 per cent of all of the accidental deaths occurring in this country. In 1941 we had over 1000 children scalded to death, and we do not know how many more were scalded and lived, since the mortality figures do not include those that lived. It is thus evident that, even in peace times, bums take a tremendous toll of lie. Boston and the surrounding suburbs are composed of frame buildings. Even a token bombing or a fairly small piece of sabotage could set most of Boston on fire, and if that did happen, the problem of bums would assume major importance immediately. Three years ago there occurred in a Charlestown freight yard a fire that did not involve human lie. It took every available piece of Boston fire apparatus and the spare apparatus of 21 surrounding towns to combat the fire. In England, during the height of the blitz, London had 79 fires in one night, all of them bigger than the Charlestown fire. This is an example of how helpless we would be if we did have a bombing in or around Boston. Visits to clinics and hospitals throughout the country would disclose that bums average a mortality somewhere between 35 and 45 per cent. It is thus evident that burns not only occur frequently, but that when they do occur they produce a tremendous number of deaths. It is further evident that we have not yet the answer to all of the problems of treatment. At the present time there are four so-called modem forms of treatment. Abstract of an address given at the 222nd meeting of the N.E.A.C.T.a t Tufts College, Medford, Massachusetts, May 15. 1943.
The tannic acid treatment was brought out in 1925 by Davidson of Detroit, although he was antedated by other persons. In 1895 an anonymous writer in the Pittsburgh Medical Gazette advocated the use of a 5 per cent solution of tannic acid, but the suggestion did not gain acceptance and was soon forgotten. In 300 A.D. the Greek peasants treated burns with black ink, made by boiling nut shells and bark containing tannic acid. Hippocrates, the father of medicine, about 200 R.C. left us four prescriptions for burns; three were for some form of oil or fat, but the fourth was made from white wine and an extract of ilex, a holly tree that contains much tannic acid. So Hippocrates himself was using the tannic acid treatment. Even 400 years before him, the Chinese were treating burns with strong tea as a wet dressing, and this contains an appreciable amount of tannic acid. It is thus evident that this method of treatment has come in and has gone out a number of times. All of the older forms of treatment aimed a t allaying pain. Nothing was known about the toxemia or sickness caused by bums. It was believed up to 1900 that if one-third of the body was burned there was no possible chance of saving life. The main aim was to cover the burned nerve endings to keep away air and thus stop pain. In 1902 investigators began to wonder about the cause of toxemia and death from burns. For the first time research was started and theories advanced to explain this toxemia and the resulting deaths. The first theory we can call the loss of skin function as it was known that loss of one-third of the skin was fatal. It was assumed that death would ensue when there were lost from such an area the three functions of the skin: heat regulation, sensation, and excretion. This theory is interesting only from a historical point of view, because it has been found that all functions of the entire skin can be obliterated without causing death. Two years later the theory of toxic absorption was advocated. Investigators stated that there was formed in the site of the burn, and probably produced by the action of the heat on the skin proteins, a "split protein" which caused the toxemia by being absorbed. Each investigator described his own split protein as the one causing the damage, and a t one time or another
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many such compounds have been mentioned, including all of the ptomaines, pyridine, guanidine, and primary and secondary proteoses. No two investigators were able to agree as to what the split protein was, but in general i t was believed that there was such a substance and that this caused the pathological picture seen in burned patients. This rather chaotic state of affairs went on until 1923, when Robertson and Boyd made an extract from the burned skin of a dog. When this extract was injected into an unburned animal, the animal promptly showed signs of toxemia. They analyzed this extract and described i t as a primary and secondary proteosis. Their work seemed so conclusive that everybody felt that the subject was solved, once and for all. As a matter of fact, it was on their evidence that Davidson, two years later, brought out the tannic acid treatment. He was attempting to convert the burned surface into an insoluble crust to prevent absorption of the poison from the surface into the body. Shortly afterwards, Underhill began repeating the experiments of Robertson and Boyd. He had conducted a great deal of work on the shifting of water balance in the body following injury. He knew that when trauma takes place there is a transference of plasma from the blood stream into the injured area. I t seemed inconceivable to him that a toxin could be absorbed against this shift of fluid. Although he could get the same toxemia from an extract of the burned area, he reanalyzed this extract and found that it contained appreciable amounts of ethyl alcohol. When he injected this quantity of alcohol into an unburned animal, toxemia again resulted. He chose to call this "intoxication," and it became evident that the primary and secondary proteosis of Robertson and Boyd was simple ethyl alcohol. Underhill then conclusively disproved the theory of toxemic absorption by showing the improbability of absorption from the burned surface back into the body. Dogs were burned under ether anesthesia and divided into three groups. Trypan hlue was injected into the burned areas of group No. 1, methylene hlue into group No. 2, and five times the lethal dose of strychnine into group No. 3. In the first two groups no dyes could he detected in the blood stream or in the urine, and no animal in group No. 3 showed the slightest sign of strychnine poisoning. If, then, these substances are not absorbed in sufficient quantity to be detected, it is highly inconceivable that a vague split protein can be absorbed in all large burns and produce the inevitable signs of toxemia. Underhill then proceeded to postulate a theory of his own. He reasoned that there is such a marked shift of plasma from the hlood stream into the edema fluid of the burn that a concentration of the solid matter of the hlood takes place. He showed in experimental animals that it is possible to produce a hemoglobin of 240 per cent, and it is well established that a hemoglobin of over 140 is not compatible with life for a very long period of time. He assumed that this hemo-concentra-
tion is the cause of toxemia and death and that success in keeping the blood chemistry normal should counteract it. Soon Underhill was presented with 23 badly hurned patients a t once from a local theater fire. He hospitalized all of them, called in physicists and chemists, and attempted to maintain a normal blood chemistry. His treatment was very good for the shock phase, but in the end he lost 7 of the 23 cases. His own mortality figure exploded his theory, and from the work he had done there was no way to explain the deaths that took place weeks and months after the bums occurred. This was the status of bums in 1928. All of the accepted theories had bee& exploded, and all we knew was that bums of one-third of the body area were fatal. At Johns Hopkins we had been running a mortality of 42 per cent for 10 consecutive years, meaning that we were losing all of our big burns, especially those occurring in children. It was rather a pathetic experience to see a freshly burned child brought in with involvement of more than one-third of the body and have to tell the paients that, although the child did not look too bad a t the time, theie was no chance of saving its life. The most that we could do was to assure the parents that enough morphine would be given to bring about an easy death. In 1920 we began research on the problem of burns. During the first year we reviewed all of the older forms of treatment that seemed to have any rational basis. We used all of the salves, ointments, and pastes that had been advocated. We used tannic acid, picric acid, complete debridement, exsanguinatiou, and transfusion. The results showed that tannic acid and transfusions would reduce the mortality from 42 to 32 per cent, but we still were not satisfied that 32 per cent represented any real advancement in the treatment. Shortly after that, for a time, we had to return to the dry heat method. This consists of putting the patient nude in bed under a cradle, over which the sheets or blankets were suspended. Under the cradle we had a light bulb to keep the temperature between 100' and 104'F. This was supposed to induce an exudation from the patient to prevent the absorption of poison. The heat dried the plasma, converting it into a crust which was supposed to stop pain, but also made an excellent place for the growth of germs. This resulted in a return to our original mortality of 42 per cent. The experience made us conscious of the fact that we had never seen a large burn that did not a t one time or another exhibit pus on the burned surface. Since a review of the literature showed that no work had been done on the bacteriology of the burned surface, we began to culture it every four hours from the time of admission for 72 hours. For 18 hours the results showed sterility or a light contamination. From 18 to 40 hours there was a mixed infection of all germs of the air and of the materials touching the patient, and this became increasingly heavier. During the period from 40 to 72 hours, however, a peculiar change took place, and a t the end 100 per cent of the larger burns showed a pure
culture of one strain of streptococcus. There are about When a burn takes place, the first-aid person should 200 strains of this organism, four or five being quite attempt to put the patient a t complete rest and get him common. One of these four or five would outgrow all warm. The burned surface should be iznored because other germs and would exist in pure culture after three it is obvious that anything done to the burn will cause days. It seemed inconceivable to us to ignore this the patient more pain, or will chill him or keep him from streptococcus pus, bathing a large surface of the body, havine comolete rest. Once the natient has been takeu and still search for some split protein as the cause of to the hospital we can stop all pain with large doses of toxemia in bums. morphine and can begin the intravenous administraAs a result of the bacteriological work, we brought tion of plasma. Only after the patient is out of shock out the theory of infection. If this is the cause of can we begin treatment of the local area. This leads us into the local treatment of the burned toxemia, the logical form of treatment is one aimed a t surface, and we will discuss the tannic acid treatment minimizing or preventing the infection. In 1912 Churchman had shown that gentian violet is first. This was very popular a t the beginning of the one of the most potent antiseptics that we have against present war. I should like to describe how i t is used in gram-positive germs and will not injure a single living the Henry Ford Hospital, which is the stronghold of cell of the body. The streptococci are all gram positive. tannic acid. When a freshly bumed case is received, In 1925 I had repeated this work, and in 1929 i t occurred they treat for shock immediately and continue it for to me that a 2 per cent solution of gentian violet could about four hours. Then the patient is taken to the be sprayed on the burned surface to prevent or minimize operating room, where he is anesthetized, and the the infection. When this was done, i t was discovered burned areas are thoroughly scrubbed for a half hour that gentian violet had a quality that we did not know with soap and water. This is done a t the end of four about. It was able to combine with the upper layer of hours, for if they wait longer, contamination of the the burned surface to form a light, flexible crust. This burned surface takes place and they are unable to put crust sealed off the bumed nerve ends, thereby stopping tannic acid on such an area. After the tannic acid is pain. It prevented fluid loss, thus minimizing the sprayed on, it is followed by a 10 per cent solution of plasma loss, and acted as a layer under which to grow silver nitrate. This causes a precipitation of proteins new skin. In addition t o these good qualities, we in the skin and forms a crust very rapidly. The pafound that in the first year gentian violet was used on tient is then taken back to the ward, where the shock burns a t Johns Hopkins, the mortality was reduced treatment is again started if necessary. After three from 42 per cent to 12 per cent. weeks, during which time the patient is not much of a At Boston City Hospital, when the dyes were used in problem, he is again taken to the operating room and all five of the surgical services, we never ran a mortality the crust is dissected away under anesthesia. Then higher than 8 per cent. Frequently, over a period of immediate skin grafting is done if possible, or the months, it has been as low as 2 per cent; in 1940 up to bumed surfaces are treated with wet dressings until September it was under 2 per cent; during the remain- the granulation tissue builds up to the point where it ing months of the year a number of total burns came in will accept skin. Objections to the tannic acid treatment are as that brought the mortality for the year up to 8 per cent. Before the use of dyes, from 1919 to 1930, the average follows: Many times it is impossible to anesthetize a severely burned patient a t the end of four hours; his mortality had been about 28 per cent. Before going into the treatment of bums, the various state of shock is too profound, and to do so would phases that a patient goes through should be described. probably bring about death. The tannic acid and silver This will give us a clearer picture of the burned person nitrate combmation is not kind to injured epithelium as a whole, and will indicate the necessity of first aid for and frequently produces a more severe bum. At the bums and how they should be handled in the later end of three weeks, many deep bums are not in a position to be skin-grafted, and the secondary treatment phases. A bumed patient first goes into the shock phase. with wet dressings is m l l y going back to an obsolete Following this, if he lives, he passes through a long method which is no longer considered good. Practically period of infection, during which there is invasion of the every second-degree burn treated with silver nitrate and body by the streptococcus, and finally he goes into the tau& acid becomes a third-degree case, and every convalescent phase, which requires skin grafting, a third-degree burn is deepened to the point where skin grafting will be necessary. rehabilitation, and so on. At the beginning of the war, the British were using The shock phase is the most important a t first; actually in a large bum, there is no first aid for the tannic acid on most of their bums. The earlier cases burned surface. The shock syndrome, which sets in were pilots of the RAF. When their planes caught immediately following the burn, is characterized by a fire they had to bail out and usually ignited their clothfall in blood pressure, an increase in pulse rate, and a ing as they did so. As they came down, the wind fanned decrease in the cardiac output. The four fundamentals the fire up into the face, and when they reached up to for treating shock are: (1) complete rest; (2) applica- pull their shroud lines to guide their parachutes they tion of local heat; (3) control of pain; and (4) in- received bums of the hands. These early patients were treated with silver nitrate and tannic acid, but it was travenous fluids.
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soon found that after the third or fourth day the eyelids began to slough off, and later the lips. After several months of this experience, the Air Ministry forbade the use of tannic acid on bums of the hands or face. After the evacuation of Dunkirk, a majority of the bums were cared for by Commander Keating, who later was in charge of the medical service on the H.M.S. "Rodney." When the "Rodney" was in Boston for repairs some two years ago I had a chance to discuss with him his experience with tannic acid treatment. He stated that he was well pleased with the immediate results but that, when he had a chance to observe the patients a t a base hospital six weeks later he found that for most of the encircling bums of extremities amputation had become necessary, because of the constricting action of the crust formed by the tannic acid. His experience was followed by that of others, to the point where the government finally forbade the use of tannic acid on all burns of the hands, face, and genitalia, and encircling bums of the extremities. If tannic acid cannot be used on these areas, i t is quite obvious that it should not be used a t all. In this country a year ago last June, an editorial appeared in the Journal of the American Medical Association, indicating that tannic acid can and does cause a central necrosis of the liver. A great many cases that we used to believe died from shock were actually the result of tannic acid poisoning. These facts indicate that tannic acid can no longer be used on burns. In the past three years the sulfonamides have been used on burned surfaces. As yet no one has reported a large enough series to indicate the value of these drugs. They have been used in the form of solutions, ointments, vanishing creams, and powders. It is quite obvious that the sulfonamides are not good in the presence of frank pus, and that by applying them to the burned. surface i t is quite possible to elevate the blood content to a fatal level. A year ago last November Dr. Pickerell, of Johns Hopkius, reported 115 burned patients treated with a 3 per cent solution of sulfadiazine, and with only one death. However, close scrutiny of his paper discloses that 100 were outpatient bums. This means they were patients suffering from small burns such as of the finger or spot-burn of the hand. Out of 15 that were serious enough to be admitted to the hospital, 14 were less than one-fifth of the body area; one was a bum of 80 per cent of the body, a little girl eight years old. She died a t the end of 48 hours. Her death probably was inevitable, but a t autopsy it was discovered that her renal tubules were blocked with sulfadiazine crystals. So far as I know, Dr. Pickerel1 is the only investigator who includes outpatient burns in his mortality figures. There have been 17 deaths reported due to absorption of sulfadiazine from the burned surfaces. For the time being, a great deal more work must be done on the sulfonamides before they can be accepted, and I think it is better to keep a conservative view of this form of treatment.
The pressure bandage for the treatment of bums was brought out recently by Sumner Koch of Chicago. He advocated the pressure bandage in an effort to stop the loss of plasma into the burned tissues. His technique is to put sterile vaseline directly over the wound and to cover that with a thick wrapping of sterile mechanics' waste. Around the whole he puts an Ace bandage to obtain the necessary pressure. This form of treatment was used by physicians a t the Massachusetts General Hospital following the Cocoanut Grove disaster. They knew that they could not control infection with this type of dressing and attempted to accomplish this by giving sulfonamides by mouth. Most of them are well satisfied with this form of treatment, but the fact remains that they did not save any case that had been burned over one-third of the body area; they did not prevent fever, and they did not prevent the formation of pus on the burned surface. If such a form of treatment does not save the larger burns, i t is quite obvious there is something wrong with it and that the mortality will never be reduced by practicing it. The gentian violet treatment for burns was modified in 1934. This dye had one important weakness: it was not a strong antiseptic against gram-negative organisms. At the end of a week or ten days the crust, which had remained dry, would suddenly become moist and would be found floating on a pure culture of the colon bacilli. In an effort to prevent this gram-negative infection, I combined crystal violet with brilliant green and neutral acriflavine to obtain a strong antiseptic against both the gram-negative and gram-positive germs. The combination of dyes also formed the same type of crust as we obtained with gentian violet. The technique for using the dyes is quite simple. When a fresh bum comes in, we disregard the burned surface completely. The patient is wrapped in a blanket or put in bed with an electric blanket over him. The foot of the bed is elevated in order to allow better circulation to the trunk and head. We estimate the amount of shock present by the clinical picture and by laboratory tests on the blood. If the patient is in shock. we expose one ankle and cut down on the saphenous vein. This is cannulated, and intravenous plasma is given. Only after the patient is out of shock and free frem pain do we begin treatment of the burned surfaces. At times, if the burns are not too severe and the patient is not badly shocked, we can remove his clothes, place him under a cradle, and treat the burned surfaces as the plasma is running in. Frequently we have to wait 18 to 24 hours before we can begin the local treatment. This indicates the importance of treating shock. If the patient has been lucky enough to escape being covered with butter or lard or some other form of grease or oil, we do not have to clean the surfaces before we spray on the dyes. If the bums have been treated with some of these substances, we gently pat the burned areas with a sponge wet with ether. This does not cause the patient much discomfort and removes the oily substances. Any blisters are trimmed away completely. Loose pieces of skin are cut away, and then the dyes are
applied by spraying on from an atomizer. After the first coat is dry, we apply a second coat, and so on, until the patient has had about six coats. This develops a thin, flexible, elastic, soluble crust. When this is formed, we discontinue the spraying and treat the patient with supportive measures. I wish I could tell you that this is all you have to do to take care of a bum and that, once the crust is formed, you can stand by and watch the patient get well. As a matter of fact, when the crust is formed the work is just begun. In an ideal burn-that is, a burn that can be exposed to air and kept uppermost-it is perfectly possible to have the healing progress under the crust with no infection. Unfortunately, most of the big bums are not ideal, and involve both the front and back of the body, or involve one of the orifices of the body. In such cases, contamination is so profuse that it is impossible to keep the surface completely sterile. Infection will creep under the crust and cannot be reached by spraying the crust again. However, the crust from the triple dye betrays infection immediately; the pus dissolves and softens the crust directly over it and frees it from the underlying structures. This softened area can be elevated and trimmed away with scissors. The exposed portion is then wiped dry with a sterile sponge and sprayed again. This spraying goes on daily until the underlying structures are built up to the point where they will accept a skin graft or until new epithelium grows over the raw areas. This process goes on frequently for weeks and months. The crust formed by the triple dyes is an elastic one which does not set for 24 to 48 hours. If any swelling occurs after the dye is on, the crust will stretch and will not constrict the circulation; hence i t is possible to use the dyes on burns of the hands, face, lips, or any other part of the body. The axiom that one-third of the body burned is fatal is no longer true. At the Boston City Hospital a victim of the Cocoanut Grove disaster had a burn of 67 per cent of the body area. This bum was treated with triple dyes and is the biggest to survive the disaster.
In the Cocoanut Grove affair there was a great deal of controversy over the presence of a poison gas but, so far as I know, there is no indication that such a gas was present. The rapid deaths, especially in those who had small surface burns, were brought about by inhalation of superheated air. The New York fire department for the last 15 years has been conducting educational campaigns to show people that the temperature inside of a burning building or a burning room can go up to 200°4000F. in a very few minutes. You can demonstrate this to yourself by lighting several newspapers in the fireplace. If you have a thermometer that will register the temperature, you will find that it goes up to 200° within a few feet of the flame within one or two minutes. This superheated air will bring about a rapid burning of the lungs if i t is inhaled. Victim after victim, on reviving, told the same story: inability to breathe and the rapid loss of strength. Autopsies on the dead victims showed the amount of lung destruction that was induced by this inhalation of heated air.
Notes The 224th meeting of the N.E.A.C.T. will be held at the Massachusetts College of Pharmacy, Boston, Massachusetts, on December 4,1943. High-school teachers seeking visual aids to effective teaching should become acquainted with the film catalog, "An Index of Educational and Visual Training Slides, Motion Pictures, and Sound Films," Westinghouse Electric and Mfg. Co., Motion Picture Division, General Advertising Department, Pittsburgh, Pennsylvania. The Association went on record as endorsing the proposal for the United Science Front, and this will be found in the High-School section, page 562 of this issue of the JOURNAL. Elbert C. Weaver, Associate Editor of THISJOURNAL, has left Bulkeley High School, Hartford, Connecticut, to teach chemistry a t Phillips Academy, Andover. Massachusetts.
