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Treatment and management of burn cases
TREATMENT
AND MANAGEMENT H. JERRY LAVENDER,
OF BURN CASES*
M.D.
Attending DermatoIogist and SyphiIoIogist, Cincinnati General and Jewish HospitaIs CINCINNATI,
has been written during the past fifteen years regarding the treatment of extensive burns, and especiaIIy of the use of agents such as tannic acid, gentian violet, acrivioIetbrilliant green, siIver nitrate, etc., aIone or in various combinations. These chemicals, when appIied to the burned areas, mix with the exudate to form crusts or Ieathery protective coverings. Ten to tweIve hours, often fifteen to twenty hours, are required to obtain a leathery coating of the desired consistency. This form of treatment has been hailed by most investigators and generaIIy accepted by the medica profession as a Iife-saving measure and the best treatment thus far advanced. Advocates of this method claim in the main that it is a big factor in reducing shock, relieving pain, preventing Ioss of tissue and body fluids, heIping to minimize the toxic stage, controIIing sepsis, and speeding recovery. AImost without exception, however, the authors emphasize that the patient shouId be given the anti-shock measures commonIy empIoyed; that fluids be given in large quantities parenteraIIy and by mouth (when possibIe); that narcotics or potent anaIgesics be administered to control pain; that provisions be made to contro1 secondary pyogenic invaders; and that bIood transfusions are very important. It wouId appear then, that the crust-forming method affords the patient a protective or Ieathery coat in the burned areas, but that the fluid Ioss, pain, toxemia and sepsis have to be met with other measures to enhance restitution and recovery. No discrimination has been made up to this point between burns caused by fire and those caused by scaIds. AIthough I do not consider the crust-forming method as the
M
UCH
OHIO
one of choice in either event, I might accede to its use in scaId cases, but not in those caused by fire. It may be stated in genera1 that most burns produced by scalds are not so deep as those caused by fire; aIso, that the extent and depth of an injury produced by scaIds can be determined within a few hours after the insuIt, whereas severa days, sometimes a week or Ionger is necessary before the same visualization can be accompIished after fire. The reason for this is quite obvious. UnIess the individual is subjected to a medium of constant therma potency (several minutes or Ionger), the damage or invoIvement after scaIds will be much more superficial, due to the fleeting or disseminating property of the scalding Iiquid and its rapid Ioss of heat. Using the same time element, fire wiI1 produce a much more intense and a deeper burn. AIso, it may be stated that, as a rule, scalds wiI1 manifest more inflammatory and buIIous (exudative) reaction than fire burns, the Iatter cooking the flesh to such a degree that the vast majority of the areas are dry and remain so for severa days. The exudative processes are seared off, so that there is very IittIe loss of tissue or body fluids. The seared tissue thus acts in the same manner as a Ieathery covering, differing, however, in depth and consistency. What is the advantage gained by covering this aIready dry area with an additiona coating? It must be admitted that depth pIays a r81e in the restoration of the tissues; also, that intenseIy cooked or burned tissue is, in the majority of cases, dead tissue. Dead tissue acts as a foreign body and restoration cannot take pIace without a separation and sIoughing of this dead or gangrenous materia1. This is part of the body’s defense
* From the department of DermatoIogy, Service of Dr. EImore B. Tauber, Cincinnati General Hospital. 434
NEW SERIES VOL. XLV. No. 3
Lavender-Burns
mechanism, and the Ieathery coat or crust does not, and for obvious reasons cannot, prevent this separation or sIoughing. On the contrary, in the vast majority of cases, not onIy does the sloughing take pIace, but the crust, unIess removed, sIows the heaIing process and traps any pyogenic exudate underneath its tough covering. If we accept the theory, of the origin of the toxic stage whoIIy or in part as a resuIt of the absorption of split proteins, or if we wish to recognize the theory of the absorption of toxic materia1 from secondary pyogenic invaders, we certainIy couId not prevent absorption of toxins from the deepIy burned areas by manufacturing a crust over the burn. No matter how aseptic the technique in appIying the crust, when the trauma of the burn invoIves tissues deeper than the epidermis, sloughing must ensue for proper heaIing and before complete restoration, with or without grafts, can take pIace. This refers, of course, to deep or “third degree” burns. CertainIy no one wouId consider grafting an area which was obviously unclean. By the same token then, why resort to some measure in deepIy burned areas which not onIy does not enhance the heaIing, but is contrary to a11 the Iaws of natura1 body defense? It is aIso iIIogica1 to maintain that the Ieathery coat or crust makes the patient more comfortabIe and heIps to tide over the interva1 unti1 sloughing takes place. As stated previousIy, it usuaIIy requires several hours for a desirabIe coaguIated area or firm crust to form. If the burn is extensive, with severa areas involved, it means constantIy changing the position of the patient in order properIy to appIy the crusting agent-certainIy not a comfortabIe procedure for the patient. Even after the crust is firm and hard, it is much more d&uIt to change position from time to time for relaxation or further comfort. The castlike coating precludes this where extremities, and especiaIIy joint areas, are invoIved. If the crust has to be arranged in band-Iike formation, especiaIIy on the
American
Journal
of Surgery
535
extremities, it impedes circuIation, acting as a tourniquet. I fuIIy realize that dehydration pIays a big r81e through the rapid and enormous Ioss of bIood and body ffuids, but even in untreated extensive (area considered) superficia1 burns with a marked inff ammatory and exudative process, the transudate or oozing of fluids into the burned areas wiI1 subside within a few hours. In fact, many of the cases are first seen severa hours after the trauma is effected, and after most of the Auid loss has taken place. This Ioss must be met by parentera administration of Auids. The leathery crust offers no heIp where the damage has aIready occurred or where the process of fluid Ioss has aIready greatIy dissipated itseIf. Therefore, the genera1 supportive measures which are necessary in every case, i.e., intravenous soIutions, bIood transfusions, proper nourishment, etc., are the actua1 .eIements which buiId up the resistance, heIp the natural defenses and carry the patient through-not the coaguIum. Many of the statements in the foregoing discussion may seem dogmatic, but I have been forced to these concIusions after carefu1 study and evaIuation of many methods and after the supervision of over 2,000 burn cases. My method of choice, in the vast majority of the cases, is the use of a modified, aImost forgotten, water-bath or tubbing procedure. The patient shouId be hospitaIized. FreshIy burned areas, that is, those seen within the first few hours, are not disturbed for at Ieast ten to tweIve hours. The patient is mereIy wrapped in a steriIe sheet. This permits a more compIete manifestation of the intensity of the burn, and the nature and extent of the injury are better visuaIized. In the interim, anti-shock measures are enforced. This incIudes the usua1 procedures of eIevating the foot of the bed, warm covers and heat appIications, warm intravenous soIutions (the first usuaIIy containing 5 to 10 per cent gIucose), stimulating drugs, absoIute quiet, etc. The
336
American
Journal
of Surgery
Lavender-Burns
patient is typed and matched as soon as possibIe and a bIood transfusion given during the first twenty-four hours. Thereafter, bIood is given often, and the pushing of fluids continued, depending upon the genera1 condition. SuprarenaI cortex extract has proven to be efficacious as a proIonged stimuIant, and in many cases it was feIt that it acted as a life-saving measure during both the shock and toxic stages. No morphine or aIIied preparations are used before the patient voids. To begin with the shock produces an oIiguria or even an anuria, and to tie up the excretions or proIong the anuria is unwise. If the patient is in a stage of excitement when first seen, or is quite restIess or hysterica1, one of the barbiturates wiI1 usuaIIy have the desired effect. Morphine is not necessary in earIy cases for the contro1 of pain, since IittIe or no pain is experienced after the first severa minutes of the injury. The shock stage precludes this, and the deeper the shock the Iess pain, discomfort or restIessness. OnIy after the initia1 rest period and when the patient is compIeteIy out of shock, are the burned areas attended to. After the administration of a mild narcotic, the patient is Iifted into a Iarge bathtub fiIIed with hot water ( IOO’F.), to ,which has been added about one pint of aqueous green-soap soIution. * This is a much better preparation than the tinctured soIution, in that it is non-irritating and, in fact, very soothing. There is onIy a minima1 amount of discomfort, Iasting just a minute or two when the patient is fn-st tubbed. AI1 the torso and extremities are compIeteIy submerged; a head rest with an inflated rubber ring wiII keep the head free. Canvas hammocks fastened with hook arrangements to the sides of the tub and adjusted with ease, may be used; they cause IittIe or no discomfort due to the buoyancy of the body in the fuI1 tub. * The soap soIution is prepared in the same manner as the ordinary tincture bf &en-soap (U.S.P.) except that distikd water reDlaces the aIcoho1 and the oil of lavender is eriminated-. The preparation is, of course, filtered.
The individua1 is observed very cIoseIy and is permitted to remain in the soap solution for five to ten minutes only, depending upon the genera1 condition and toIerance. He is then Iifted to a steriIe sheet, and a mechanica debridement of a11 bIisters and Ioose tissue is done as asepticaIIy as possibIe, using smaI1 pieces of steriIe gauze. Care must be exercised to get the areas as cIean as possible, especiaIIy the edges of the wounds. The whoIe cleaning up procedure shouId not consume over four or five minutes, even in an extensiveIy burned patient. Dressings of warm diIute Burow’s soIution (2 ounces to the quart of water) are then appIied to a11 areas involved. For this purpose steriIe strips of oId Iinen or cotton materia1 shouId be used, and severa Iayers appIied. Gauze dressings are avoided to prevent firmer adherence or sticking to the wounds. The dressings are kept wet continuousIy with the warm soIution, but are not changed or removed unti1 the next tubbing period, the foIIowing morning, at which time the patient is pIaced, dressings and aI1, in the bath containing the soap soIution. After severa minutes of soaking, the dressings graduaIIy ffoat away from the wounds without any Iifting or puIIing, and with no discomfort to the patient. The Iength of stay in the tub is now increased to twenty or thirty minutes, again depending on the toIerance, after which fresh dressings of diIute Burow’s soIution are appIied in the same fashion as previousIy described without cIeaning off the soap soIution. The norma skin areas are hurriedIy dried, either with a soft towe or a warm-air eIectric bIower. This is a daiIy procedure. Upon being returned to bed, the patient is observed for secondary shock, which, if it does occur, is usuaIIy very miId. After this the head and chest of the patient shouId be eIevated to prevent hypostatic invoIvement, his position being changed every few hours for a similar reason. It is not unusua1 for the patient to faI1 asIeep after the bath, the tubbing procedure act-
NEW SERIES VOL. XLV, No. 3
Lavender-Burns
ing as a soporific; it is not uncommon for dozing to occur in the tub. On the third or fourth day the patient wilI usuaIIy toIerate a fuII hour of tubbing and this may be increased graduaIIy to severa hours per session. The patient is then tubbed twice daily, in the morning and again in the Iate afternoon or evening. AI1 but the head is compIeteIy submerged in order to prevent chilling, and the water shouId be kept at a reIativeIy constant temperature. WhiIe he is in the bath, tap water may and shouId be given freely, and fruit juices may be added. It is interesting to note with what pIeasure patients anticipate the bath procedure; they are, quite often, reIuctant to be removed from the tub. The water affords compIete reIaxation, reIieving muscIe spasm, pain or discomfort. Movements of the extremities can be accompIished with very IittIe effort. Many patients prefer motion in order to reIease or remove the dressings themseIves, and they become interested in this procedure. With these daiIy miId exercises, contractures are, for the most part, either prevented or reduced to a minimum. It is rarely necessary to resort to some orthopedic appIiance, but when necessary, this can be appIied much earlier by the tub method because the nature and extent of the impending contracture or deformity can be anticipated sooner. Due to the fact that the dressings are not moIested, and that they reIease themseIves in the bath, the new granuIation tissue is not disturbed: this is an important factor. Another factor of even greater importance, is that the wounds are cIeansed by the weak soap solution, which reduces secondary infection to a minimum. OccasionaIIy a pyocyaneus infection is encountered and is treated with a I per cent soIution of acetic acid. The odor of pyoso characteristic of genie invoIvement, burned areas, is absent. With cIeaner areas, granuIations form much faster, and the manifestation of epitheIia1 isIands may be watched from day to day.
American
Journal
of Surgery
537
In third degree burns, the gangrenous tissue separates and sIoughs much more rapidIy, and as this process takes pIace the base of the sIoughing area remains clean. This makes for a much faster restoration and proIiferation of epitheIia1 tissue. Even after the sIoughing is compIeted, the raw surface wiI1 in many instances deveIop smaI1 indented areas here and there, which turn out to be new isIands of epithelium. As Iong as this process continues the tubbing is kept up unti1 the areas are compIeteIy heaIed. If the heaIing process appears to be at a standstiI1, the patient is prepared for skin-grafting. If grafting is necessary, the areas are almost ready for it without further preparation. Many of these cases have undergone grafting without dakinization, and with good resuIts. If dakinization is necessary, it is onIy for one or two days, using weak soIutions. If the area to be grafted manifests exuberant or hypertrophic tissue, the Dakin’s soIution wiI1 reduce them to skin IeveI in most instances, providing that it is appIied earIy and before hardening or compIete organization of the scar tissue takes pIace. If one area heaIs in advance of another, the wet dressings are repIaced by 3 per cent boric unguent in the heaIed areas. VaseIinegauze may aIso be used. Most investigators wiI1 agree that in facia1 burns, even intensive ones, restoration and healing wiI1 take pIace much more rapidIy and with Iess scarring than in other areas. The wet dressings with Burow’s soIution wiI1 suffice to bring about a proper response in most cases. OccasionaIIy a 2 or 3 per cent ammoniated mercury ointment may be used to prevent or restrain secondary pyogenic infection. Infants and chiIdren respond unusuaIIy we11 to the bath method of treatment. Their handIing is, of course, reIativeIy simpIe in comparison with aduIts, as they may be lifted in and out of the tubs with ease. AduIts, however, very soon become adapted to the manipuIation, and their anticipation of the soothing and reIaxing
538
American
Journal
of Surgery
Lavender-Burns
effects of the bath more than compensates for the effort invoIved in getting them there. Water toys heIp greatly, in amusing chiIdren and in getting them to move various members of the body as they play. CONCLUSIONS
Accurate comparative statistics for different methods of treatment are not avaiIabIe; comparisons may be made only when like conditions arise. The Iocation, the extent of cutaneous involvement, and the depth of the burn, the age of the patient and the burn itseIf, together with the general management and treatment, must be considered, as a11 pIay an important r81e. One patient with a reIativeIy superficial and limited involvement, may die of a compIication such as pneumonia, erysipeIas, or post-surgica1 scarIet. Another, extensiveIy and intensiveIy invoIved and with a poor prognosis, may sail on to a reIativeIy uneventfu1 recovery. Therefore, deductions as to efficacy of therapy can be made only on a general basis, after thorough practica1 application and experience.
I feel that the bath or tubbing procedure, as outIined, far surpasses any other form of therapy advocated. Its advantages over the protective-crust or coagulum method are manifoId, and may be summarized as foIIows : I. Epithelial proIiferation and new granuIations not disturbed, thereby enhancing recovery. 2. Burned areas are kept much cIeaner. 3. No coaguIum to trap pyogenic infection. 4. Separation and sIoughing of dead tissue occurs more rapidly, leaving cIeaner base. 5. Contractures and adhesions are prevented by movement of invoIved parts; orthopedic intervention may be started earlier. 6. Areas are ready for grafting earlier. 7. The procedure is soothing, comfortable, and practical. 8. No irritation or deIeterious effects, attributabIe to the soap soIution, have been observed in any case.
AND MANAGEMENT H. JERRY LAVENDER,
OF BURN CASES*
M.D.
Attending DermatoIogist and SyphiIoIogist, Cincinnati General and Jewish HospitaIs CINCINNATI,
has been written during the past fifteen years regarding the treatment of extensive burns, and especiaIIy of the use of agents such as tannic acid, gentian violet, acrivioIetbrilliant green, siIver nitrate, etc., aIone or in various combinations. These chemicals, when appIied to the burned areas, mix with the exudate to form crusts or Ieathery protective coverings. Ten to tweIve hours, often fifteen to twenty hours, are required to obtain a leathery coating of the desired consistency. This form of treatment has been hailed by most investigators and generaIIy accepted by the medica profession as a Iife-saving measure and the best treatment thus far advanced. Advocates of this method claim in the main that it is a big factor in reducing shock, relieving pain, preventing Ioss of tissue and body fluids, heIping to minimize the toxic stage, controIIing sepsis, and speeding recovery. AImost without exception, however, the authors emphasize that the patient shouId be given the anti-shock measures commonIy empIoyed; that fluids be given in large quantities parenteraIIy and by mouth (when possibIe); that narcotics or potent anaIgesics be administered to control pain; that provisions be made to contro1 secondary pyogenic invaders; and that bIood transfusions are very important. It wouId appear then, that the crust-forming method affords the patient a protective or Ieathery coat in the burned areas, but that the fluid Ioss, pain, toxemia and sepsis have to be met with other measures to enhance restitution and recovery. No discrimination has been made up to this point between burns caused by fire and those caused by scaIds. AIthough I do not consider the crust-forming method as the
M
UCH
OHIO
one of choice in either event, I might accede to its use in scaId cases, but not in those caused by fire. It may be stated in genera1 that most burns produced by scalds are not so deep as those caused by fire; aIso, that the extent and depth of an injury produced by scaIds can be determined within a few hours after the insuIt, whereas severa days, sometimes a week or Ionger is necessary before the same visualization can be accompIished after fire. The reason for this is quite obvious. UnIess the individual is subjected to a medium of constant therma potency (several minutes or Ionger), the damage or invoIvement after scaIds will be much more superficial, due to the fleeting or disseminating property of the scalding Iiquid and its rapid Ioss of heat. Using the same time element, fire wiI1 produce a much more intense and a deeper burn. AIso, it may be stated that, as a rule, scalds wiI1 manifest more inflammatory and buIIous (exudative) reaction than fire burns, the Iatter cooking the flesh to such a degree that the vast majority of the areas are dry and remain so for severa days. The exudative processes are seared off, so that there is very IittIe loss of tissue or body fluids. The seared tissue thus acts in the same manner as a Ieathery covering, differing, however, in depth and consistency. What is the advantage gained by covering this aIready dry area with an additiona coating? It must be admitted that depth pIays a r81e in the restoration of the tissues; also, that intenseIy cooked or burned tissue is, in the majority of cases, dead tissue. Dead tissue acts as a foreign body and restoration cannot take pIace without a separation and sIoughing of this dead or gangrenous materia1. This is part of the body’s defense
* From the department of DermatoIogy, Service of Dr. EImore B. Tauber, Cincinnati General Hospital. 434
NEW SERIES VOL. XLV. No. 3
Lavender-Burns
mechanism, and the Ieathery coat or crust does not, and for obvious reasons cannot, prevent this separation or sIoughing. On the contrary, in the vast majority of cases, not onIy does the sloughing take pIace, but the crust, unIess removed, sIows the heaIing process and traps any pyogenic exudate underneath its tough covering. If we accept the theory, of the origin of the toxic stage whoIIy or in part as a resuIt of the absorption of split proteins, or if we wish to recognize the theory of the absorption of toxic materia1 from secondary pyogenic invaders, we certainIy couId not prevent absorption of toxins from the deepIy burned areas by manufacturing a crust over the burn. No matter how aseptic the technique in appIying the crust, when the trauma of the burn invoIves tissues deeper than the epidermis, sloughing must ensue for proper heaIing and before complete restoration, with or without grafts, can take pIace. This refers, of course, to deep or “third degree” burns. CertainIy no one wouId consider grafting an area which was obviously unclean. By the same token then, why resort to some measure in deepIy burned areas which not onIy does not enhance the heaIing, but is contrary to a11 the Iaws of natura1 body defense? It is aIso iIIogica1 to maintain that the Ieathery coat or crust makes the patient more comfortabIe and heIps to tide over the interva1 unti1 sloughing takes place. As stated previousIy, it usuaIIy requires several hours for a desirabIe coaguIated area or firm crust to form. If the burn is extensive, with severa areas involved, it means constantIy changing the position of the patient in order properIy to appIy the crusting agent-certainIy not a comfortabIe procedure for the patient. Even after the crust is firm and hard, it is much more d&uIt to change position from time to time for relaxation or further comfort. The castlike coating precludes this where extremities, and especiaIIy joint areas, are invoIved. If the crust has to be arranged in band-Iike formation, especiaIIy on the
American
Journal
of Surgery
535
extremities, it impedes circuIation, acting as a tourniquet. I fuIIy realize that dehydration pIays a big r81e through the rapid and enormous Ioss of bIood and body ffuids, but even in untreated extensive (area considered) superficia1 burns with a marked inff ammatory and exudative process, the transudate or oozing of fluids into the burned areas wiI1 subside within a few hours. In fact, many of the cases are first seen severa hours after the trauma is effected, and after most of the Auid loss has taken place. This Ioss must be met by parentera administration of Auids. The leathery crust offers no heIp where the damage has aIready occurred or where the process of fluid Ioss has aIready greatIy dissipated itseIf. Therefore, the genera1 supportive measures which are necessary in every case, i.e., intravenous soIutions, bIood transfusions, proper nourishment, etc., are the actua1 .eIements which buiId up the resistance, heIp the natural defenses and carry the patient through-not the coaguIum. Many of the statements in the foregoing discussion may seem dogmatic, but I have been forced to these concIusions after carefu1 study and evaIuation of many methods and after the supervision of over 2,000 burn cases. My method of choice, in the vast majority of the cases, is the use of a modified, aImost forgotten, water-bath or tubbing procedure. The patient shouId be hospitaIized. FreshIy burned areas, that is, those seen within the first few hours, are not disturbed for at Ieast ten to tweIve hours. The patient is mereIy wrapped in a steriIe sheet. This permits a more compIete manifestation of the intensity of the burn, and the nature and extent of the injury are better visuaIized. In the interim, anti-shock measures are enforced. This incIudes the usua1 procedures of eIevating the foot of the bed, warm covers and heat appIications, warm intravenous soIutions (the first usuaIIy containing 5 to 10 per cent gIucose), stimulating drugs, absoIute quiet, etc. The
336
American
Journal
of Surgery
Lavender-Burns
patient is typed and matched as soon as possibIe and a bIood transfusion given during the first twenty-four hours. Thereafter, bIood is given often, and the pushing of fluids continued, depending upon the genera1 condition. SuprarenaI cortex extract has proven to be efficacious as a proIonged stimuIant, and in many cases it was feIt that it acted as a life-saving measure during both the shock and toxic stages. No morphine or aIIied preparations are used before the patient voids. To begin with the shock produces an oIiguria or even an anuria, and to tie up the excretions or proIong the anuria is unwise. If the patient is in a stage of excitement when first seen, or is quite restIess or hysterica1, one of the barbiturates wiI1 usuaIIy have the desired effect. Morphine is not necessary in earIy cases for the contro1 of pain, since IittIe or no pain is experienced after the first severa minutes of the injury. The shock stage precludes this, and the deeper the shock the Iess pain, discomfort or restIessness. OnIy after the initia1 rest period and when the patient is compIeteIy out of shock, are the burned areas attended to. After the administration of a mild narcotic, the patient is Iifted into a Iarge bathtub fiIIed with hot water ( IOO’F.), to ,which has been added about one pint of aqueous green-soap soIution. * This is a much better preparation than the tinctured soIution, in that it is non-irritating and, in fact, very soothing. There is onIy a minima1 amount of discomfort, Iasting just a minute or two when the patient is fn-st tubbed. AI1 the torso and extremities are compIeteIy submerged; a head rest with an inflated rubber ring wiII keep the head free. Canvas hammocks fastened with hook arrangements to the sides of the tub and adjusted with ease, may be used; they cause IittIe or no discomfort due to the buoyancy of the body in the fuI1 tub. * The soap soIution is prepared in the same manner as the ordinary tincture bf &en-soap (U.S.P.) except that distikd water reDlaces the aIcoho1 and the oil of lavender is eriminated-. The preparation is, of course, filtered.
The individua1 is observed very cIoseIy and is permitted to remain in the soap solution for five to ten minutes only, depending upon the genera1 condition and toIerance. He is then Iifted to a steriIe sheet, and a mechanica debridement of a11 bIisters and Ioose tissue is done as asepticaIIy as possibIe, using smaI1 pieces of steriIe gauze. Care must be exercised to get the areas as cIean as possible, especiaIIy the edges of the wounds. The whoIe cleaning up procedure shouId not consume over four or five minutes, even in an extensiveIy burned patient. Dressings of warm diIute Burow’s soIution (2 ounces to the quart of water) are then appIied to a11 areas involved. For this purpose steriIe strips of oId Iinen or cotton materia1 shouId be used, and severa Iayers appIied. Gauze dressings are avoided to prevent firmer adherence or sticking to the wounds. The dressings are kept wet continuousIy with the warm soIution, but are not changed or removed unti1 the next tubbing period, the foIIowing morning, at which time the patient is pIaced, dressings and aI1, in the bath containing the soap soIution. After severa minutes of soaking, the dressings graduaIIy ffoat away from the wounds without any Iifting or puIIing, and with no discomfort to the patient. The Iength of stay in the tub is now increased to twenty or thirty minutes, again depending on the toIerance, after which fresh dressings of diIute Burow’s soIution are appIied in the same fashion as previousIy described without cIeaning off the soap soIution. The norma skin areas are hurriedIy dried, either with a soft towe or a warm-air eIectric bIower. This is a daiIy procedure. Upon being returned to bed, the patient is observed for secondary shock, which, if it does occur, is usuaIIy very miId. After this the head and chest of the patient shouId be eIevated to prevent hypostatic invoIvement, his position being changed every few hours for a similar reason. It is not unusua1 for the patient to faI1 asIeep after the bath, the tubbing procedure act-
NEW SERIES VOL. XLV, No. 3
Lavender-Burns
ing as a soporific; it is not uncommon for dozing to occur in the tub. On the third or fourth day the patient wilI usuaIIy toIerate a fuII hour of tubbing and this may be increased graduaIIy to severa hours per session. The patient is then tubbed twice daily, in the morning and again in the Iate afternoon or evening. AI1 but the head is compIeteIy submerged in order to prevent chilling, and the water shouId be kept at a reIativeIy constant temperature. WhiIe he is in the bath, tap water may and shouId be given freely, and fruit juices may be added. It is interesting to note with what pIeasure patients anticipate the bath procedure; they are, quite often, reIuctant to be removed from the tub. The water affords compIete reIaxation, reIieving muscIe spasm, pain or discomfort. Movements of the extremities can be accompIished with very IittIe effort. Many patients prefer motion in order to reIease or remove the dressings themseIves, and they become interested in this procedure. With these daiIy miId exercises, contractures are, for the most part, either prevented or reduced to a minimum. It is rarely necessary to resort to some orthopedic appIiance, but when necessary, this can be appIied much earlier by the tub method because the nature and extent of the impending contracture or deformity can be anticipated sooner. Due to the fact that the dressings are not moIested, and that they reIease themseIves in the bath, the new granuIation tissue is not disturbed: this is an important factor. Another factor of even greater importance, is that the wounds are cIeansed by the weak soap solution, which reduces secondary infection to a minimum. OccasionaIIy a pyocyaneus infection is encountered and is treated with a I per cent soIution of acetic acid. The odor of pyoso characteristic of genie invoIvement, burned areas, is absent. With cIeaner areas, granuIations form much faster, and the manifestation of epitheIia1 isIands may be watched from day to day.
American
Journal
of Surgery
537
In third degree burns, the gangrenous tissue separates and sIoughs much more rapidIy, and as this process takes pIace the base of the sIoughing area remains clean. This makes for a much faster restoration and proIiferation of epitheIia1 tissue. Even after the sIoughing is compIeted, the raw surface wiI1 in many instances deveIop smaI1 indented areas here and there, which turn out to be new isIands of epithelium. As Iong as this process continues the tubbing is kept up unti1 the areas are compIeteIy heaIed. If the heaIing process appears to be at a standstiI1, the patient is prepared for skin-grafting. If grafting is necessary, the areas are almost ready for it without further preparation. Many of these cases have undergone grafting without dakinization, and with good resuIts. If dakinization is necessary, it is onIy for one or two days, using weak soIutions. If the area to be grafted manifests exuberant or hypertrophic tissue, the Dakin’s soIution wiI1 reduce them to skin IeveI in most instances, providing that it is appIied earIy and before hardening or compIete organization of the scar tissue takes pIace. If one area heaIs in advance of another, the wet dressings are repIaced by 3 per cent boric unguent in the heaIed areas. VaseIinegauze may aIso be used. Most investigators wiI1 agree that in facia1 burns, even intensive ones, restoration and healing wiI1 take pIace much more rapidIy and with Iess scarring than in other areas. The wet dressings with Burow’s soIution wiI1 suffice to bring about a proper response in most cases. OccasionaIIy a 2 or 3 per cent ammoniated mercury ointment may be used to prevent or restrain secondary pyogenic infection. Infants and chiIdren respond unusuaIIy we11 to the bath method of treatment. Their handIing is, of course, reIativeIy simpIe in comparison with aduIts, as they may be lifted in and out of the tubs with ease. AduIts, however, very soon become adapted to the manipuIation, and their anticipation of the soothing and reIaxing
538
American
Journal
of Surgery
Lavender-Burns
effects of the bath more than compensates for the effort invoIved in getting them there. Water toys heIp greatly, in amusing chiIdren and in getting them to move various members of the body as they play. CONCLUSIONS
Accurate comparative statistics for different methods of treatment are not avaiIabIe; comparisons may be made only when like conditions arise. The Iocation, the extent of cutaneous involvement, and the depth of the burn, the age of the patient and the burn itseIf, together with the general management and treatment, must be considered, as a11 pIay an important r81e. One patient with a reIativeIy superficial and limited involvement, may die of a compIication such as pneumonia, erysipeIas, or post-surgica1 scarIet. Another, extensiveIy and intensiveIy invoIved and with a poor prognosis, may sail on to a reIativeIy uneventfu1 recovery. Therefore, deductions as to efficacy of therapy can be made only on a general basis, after thorough practica1 application and experience.
I feel that the bath or tubbing procedure, as outIined, far surpasses any other form of therapy advocated. Its advantages over the protective-crust or coagulum method are manifoId, and may be summarized as foIIows : I. Epithelial proIiferation and new granuIations not disturbed, thereby enhancing recovery. 2. Burned areas are kept much cIeaner. 3. No coaguIum to trap pyogenic infection. 4. Separation and sIoughing of dead tissue occurs more rapidly, leaving cIeaner base. 5. Contractures and adhesions are prevented by movement of invoIved parts; orthopedic intervention may be started earlier. 6. Areas are ready for grafting earlier. 7. The procedure is soothing, comfortable, and practical. 8. No irritation or deIeterious effects, attributabIe to the soap soIution, have been observed in any case.