Monday, September 28, 2009

Historic Treatment of Burns

Recently, I has a request for information on the history of burn treatment, so today’s post will cover the burn section from the the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I discovered recently.

Burns

The burns of the head which the surgeon is called upon to treat are not usually very deep. The scalp is protected by hair, and if flames or steam rise into the face sufficiently to burn deeply, they will usually be inhaled and produce fatal internal injury. Most of the deeper burns of the face are, therefore, the result of a gas explosion or electric flash caused by short circuiting. The importance of avoiding a scar is, of course, very great, so that slight burns should be carefully attended to.

Burns have been variously classified according to the depth to which the tissue is destroyed. For practical purposes, they may all be placed in three classes.

Burns of the First Degree --

The symptoms are swelling, redness, and tenderness of the skin. There is no visible destruction even of the epidermis, although this usually peels off in strips a few days later. A familiar example is a mild sunburn. There is increased redness of the burned area for a week or more, but no permanent scar.

Treatment of Burns of the First Degree --

The chief indication for treatment is the relief from pain. This is best accomplished by smearing the surface with one of the lighter ointments which contains a considerable amount of water, such as rose water ointment, or one of the ointments sold under the names of Lettuce Cream, Cucumber Cream, etc. Cow’s cream is excellent for the purpose. Recovery promptly follows the application of any non-irritating substance.

Burns of the Second Degree --

Much of the epidermis within the burned area is destroyed. There are blisters either full of serum or collapsed, or the injured epidermis may have been more or less removed. Hairs within the burned area are also burned away. There is redness, swelling, and tenderness, and a more or less free oozing of serum, and possibly of some blood. Repair in this class of burns takes longer than in burns of the first degree, but no slough of the true skin occurs. If the whole thickness of the epidermal layer is here and there destroyed, these areas are very small and are rapidly covered by spreading of the deeper layer of epithelial cells. There is, therefore, no permanent scar. Redness will persist longer than in burns of the first degree, possibly for a month or more.

Treatment of Burns of the Second Degree --

The chief indication for treatment is the relief of pain. The permanent result is certain to be good. There are four plans of treatment: One is to apply a dressing soaked with oil or spread with ointment in order to protect the injured surface from the air and from changes in temperature. A second plan is to cover the burn with strips of rubber tissue or with gauze wet with normal saline solution. The third plan is to treat the burned area with an antiseptic dressing, which may be allowed to dry or which may be kept moist. The fourth plan is to leave the burned area exposed to the air in order that it may dry up. Various dusting powders are employed to further this last plan.

The author favors the first or the second of these four plans, believing that these dressings are more comfortable to the patient, and that they favor the vitality of those portions of the skin which have been injured but not destroyed by the burn; and because such dressings, provided plenty of ointment is used, or plenty of water if a wet dressing is employed, can be removed with less pain and damage than other dressings which are allowed to dry out. Powders are objectionable, since they form, with the exuded serum, hard crusts which are veritable culture tubes for bacteria. It is impossible to make or keep aseptic an area of skin which has burned below the superficial portion of the epidermis. Protection against infection depends, therefore, on the vitality of dressing. Hence, the latter should be soothing to the skin rather than deadly to the bacteria.

A good example of an oily dressing is carron oil, a mixture of equal parts of linseed oil and lime water. If this is used the gauze should be thoroughly saturated with it, as otherwise the oil will soak into the outer dry dressings, and the inner layers will become very firmly attached to the skin. For this reason an ointment is preferable in most cases. A good one is composed of one dram of boric acid to the ounce of Vaseline. The ointment should be sterilized by setting the jar which contains it in a pan of boiling water. It can, of course, be sterilized in a steam sterilizer. The ointment should be used freely. A good plan is to spread it over the burned area with a spatula, much as one spreads butter with a knife. Dry gauze can then be applied in pieces small enough to fit the part, and the dressing fixed by a loose gauze bandage.

The principle of the normal saline solution when used as a dressing for a burn is the same as when used as a dressing for a skin graft. It is to reproduce as far as possible the normal surroundings of growing epithelium. If this plan is adopted, the burned area should be immersed in a saline solution, or lightly sponged with swabs saturated with the same. It is then covered with several thicknesses of gauze saturated with saline, and evaporation is prevented by covering the whole with a sheet of gutta-percha tissue, or strips of gutta-percha tissue may be applied directly to the burned surface, and these in turn be covered by the wet gauze. When the dressing is applied in this manner, a sheet of impervious material may be applied externally, or this may be omitted and the gauze kept wet by more frequent saturation with saline or boiled water.

Picric acid is recommended by those who favor antiseptics in the treatment of burns of the second degree. Gauze is saturated with a one per cent solution, either before or after it is applied to the burned surface. This dressing is supposed to control the pain, but I have seen patients suffer severely after its employment. It has a tendency to dry up the exudate, so that in many cases burns treated in this way are greatly improved in appearance. The intense yellow color of the picric acid stains the clothing.

A mild antiseptic solution suitable for use in burns of the second as well as of the third degree, is a four per cent solution of aluminum acetate. The gauze should be saturated with it, and then kept wet by the addition of sterile water from time to time.

If it is decided to treat the burn by the dry method, it may be left exposed to the air or cleansed and dusted with a powder, such as bismuth subnitrate, or bismuth subgallate, or nosophen.

Burns of the Third Degree --

Portions of the corium, and possibly still deeper structures have been destroyed by the heat. It is easy to be misled in this matter by the early appearance of the skin. In a burn of the first or second degree the affected skin is red from the congestion of the vessels in it. If the vitality of the corium is destroyed, the blood cannot circulate through its vessels, and the skin will therefore appear white. The difference between this skin and normal skin is easily recognized if one looks for changes in color due to pressure made upon it. Such changes will, of course, be wanting in the deed skin. Furthermore, such a white, dead area will invariably be surrounded by a hyperemic zone in which the burn is only of the second degree. I have known several instances in which intelligent physicians overlooked a burn of the third degree, being misled by the lack of redness of the skin. This dead skin will, of course, slough, and in time will become entirely loose. During this process, which sometimes takes two weeks or more, there is danger that the slough will interfere with the exit of underlying pus.

Treatment of Burns of the Third Degree --

We have, then, in burns of the third degree, three indications for local treatment – the relief of pain, protection of the injured but living tissues, and drainage of any pus pockets which may form. A moist antiseptic dressing best fulfils the requirements. In most cases morphine should be given either hypodermically or by mouth during the first twenty-four hours. Few persons can sleep without an opiate the first night after a burn, even if they can endure the pain while awake.

The moist dressing should be applied warm and kept warm. The gauze may be saturated with aluminum acetate, as mentioned above, or boric acid, or any other feeble antiseptic. The dressing should be kept constantly moist, and in some instances a continuous bath is desirable.

Frequent dressings are to be avoided, but if the dressings become saturated with pus and serum, the comfort of the patient is usually promoted by changing them. Sloughs should be cut away as soon as they loosen, but not before. If a large area is burned, the central portions of the skin may loosen before the edges. If so, incisions should be made through the slough or portions of it excised to permit free escape of pus and secretions.

The repair after a burn of the first or second degree is accomplished by the normal growth of the epidermis. In every burn of the third degree the removal of the sloughs is accomplished by the growth of granulations beneath them. These granulating areas must be covered by the lateral growth of the epithelial cells, either from the edge of uninjured skin, or from islands of epithelium which have been left, or from the epithelium which line the fat and sweat glands. This new epithelium at first has no color of its own, and simply looks like a dark red glaze over parts of the granulating surface. Later, as the epithelial cells multiply, a whitish appearance results. It will be evident, therefore, in two or three weeks whether the burned area will become covered with epithelium within a reasonable time. An epithelial edge will grown about an eighth of an inch a week. A granulating area, therefore, which is an inch in its smallest diameter, will require a month for its complete repair. Areas larger than this, and which are without epithelial islands should be skin-grafted.

There is one other thing to be borne in mind during the repair, and that is the possibility of cicatricial contraction. This can be avoided to a certain extent by the judicious use of plaster bandages and splints to keep the burned area fully extended during the healing process; but a far better means of prevention is the early covering of the granulating surface with pedicled flaps, or when this is not practical, with Thiersch, or better, with Wolfe grafts. In this way the amount of scar tissue is kept at a minimum and the power of contraction will be slight.

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