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Burns
BURNS SOME EXPERIENCES IN LOCAL CARE *
By A. B. WALLACE, M.Sc., F.R.C.S.Ed.
Lecturer in Plastic Surgery, University of Edinburgh MY first article on the treatment of burns appeared twelve years ago. From the first I held that there was no one method in local care. I still subscribe to that view ; I have never wavered, but I should now like to extend it. No one method of local care has all the answers ; no one person has all the answers ; no one unit has all the answers. I do not propose to describe the exposure method in detail, nor to give the detailed treatment of separate regions--rather should I prefer to be provocative in certain directions. The principles in local care as I see them are : J I. To make the burnt area unfavourable for the growth and multiplication of organisms. 2. To reduce the invasiveness of surface organisms by avoiding moist applications and any but bland antiseptics, by keeping the part cool and immobile, and by strict nursing care. Where possible, oedema should be limited by elevating the affected part. 3. To control infection by antibiotic therapy. At the moment I think it is advisable to continue antibiotic therapy administered systemically, not locally. Yet I must express the thought that if a method of local treatment were adequate, even systemic penicillin would be unnecessary or necessary for only a few days. Methods completely dependent on an antibiotic umbrella or shield are bound sooner or later to run into trouble. In first-aid I strongly advocate the teaching of elevation of the affected part. Exposure of a burn to the air is by no means a new procedure. In its present-day form this method of treatment involves the administration of penicillin systemically, full exposure and elevation of the affected part with as much immobilisation as is practicable, and abstention from all local irritants and any form of local heating. From time to time I am told of burns treated by exposure that have gone wrong ; even the Ps. pyocyanea, which I have never found, has caused trouble. Where investigation has been possible, the local treatment has commonly been moribund inactivity and the general care lively activity. For instance, involved hands have been nursed dependent, and burnt children have been permitted to romp about the bed or be fondled by visiting parents. As with despised tannic acid, the dangers of cracks in the crust have been fully publicised. I have not found cracks to give trouble. Most are undoubtedly the result of inadequate support. In general, the more simple and elementary that principles are, the greater is the tendency to fail in their observance. * Read at a meeting of the British Association of Plastic Surgeons, Edinburgh, on 8th September I95I. 224
BURNg
225
T h e early formation o f a scab is o f paramount importance, for it protects the wound against the entrance o f pathogenic organisms, provides a framework or scaffold for young epithelium, and in deep burns presents a barrier to the loss of protein, salt, and red blood cells until it is excised and replaced with a skin graft. Nothing must be done either to delay its early formation or to disturb its integrity. In superficial burns the crust separates within three weeks and leaves a healed surface; in deep burns, w i t h i n the same interval, sloughs must be excised and skin grafts applied to the areas o f skin loss. On several occasions I have pointed out the close relationship between the so-called " pressure dressing " and " e x p o s u r e " methods. Once again I deprecate the misuse o f the term " pressure " and strongly advocate the term " absorptive dressings." T h e two forms of treatment, " absorptive dressings " and " exposure," far from being distinct as the terms " open " and " closed " sometimes applied to them would suggest, are in fact closely related and, what is more, interchangeable. Local applications preventing absorption do harm. I am very conscious o f the so-called" open " and " closed " schools of thought. T h e exposure method is commonly included under the " o p e n " school, and yet the dry crust after forty-eight hours is the most perfect " closed " dressing possible apart from living skin. T h e absorptive or pressure dressing when it becomes moist and when for one reason or another evaporation is not possible, is " open " to any and all contaminants on the covering bandages and bed-clothes. I hold that the " e x p o s u r e " method is more " c l o s e d " than even the absorptive dressing, as the surface dries quicker. I f the relationship between the two methods and the value o f each were fully appreciated, discussion would become more constructive than destructive. Some members o f American burn units in humid climes have expressed concern that exposed burn surfaces take five or even six days to crust. I can best meet this criticism by quoting from a recent letter from Lt.-Col. A. Whyte, R.A.M.C. Military Hospital, F a y i d : " We have had numerous and extensive burns treated by exposure and not a failure. M y impression is that drying and healing are quicker here. Humidity has been high the last six weeks, but a fan blowing on the burned areas has helped drying and kept flies away. Flies are a menace, but do no harm on dry scabs. Burns during the fly season we have nursed in side wards, which, being small, can be repeatedly D . D . T . sprayed and flies so controlled. I was able to confound the prophets. T h e y said exposure cannot work in sandstorms. One o f the worst cases we have had came through a three-day sandstorm and never turned a hair. T h e great advantage o f no dressings at all on burns under hot weather conditions has to be experienced to be believed. It is a crowning mercy indeed. Exposure may not be the answer to all cases, but we still have to see a failure, even under the conditions of this climate." T h e application o f biological fluids has been suggested to hasten crusting. This would at first sight appear beneficial as the earlier a dry crust forms the sooner is infection controlled. On the other hand, the escape of plasma does decompress the cedematous dermis, and must be o f considerable relief to the dermal vessels and dermal cells in dermo-epidermal burns. I would therefore advise caution with the application o f local coagulants till the optimum time for crusting is known. In my burns unit, cleansing is often done under inhalation anaesthesia (cyclopropane), which can be considered a form o f sedation. T h e burnt area is cleansed with I per cent. cetrimide or isotonic saline: blisters are snipped and
226
BRITISH
JOURNAL
OF PLASTIC
SURGERY
raised epidermis is removed. The burnt surface is then gently dried with gauze. Dusting of the involved part with a powder consisting of lactose, with the addition of io,ooo International Units of calcium penicillin per gramme, has been carried out in a large series, but I consider its local application might be omitted. If it is used locally the powder is insufflated over the burnt surface every four hours until the surface is dry (usually for forty-eight hours). Pain has not been a prominent feature. All manner of organisms fall on the burn, but they do no harm. Ps. pyocyanea and Proteus vulgaris have been grown on culture plates placed beside burnt surfaces, but have never infected the burns. One question is frequently asked: Does the exposure method of treatment increase or decrease the necessity for grafting ? What is seldom appreciated is that the necessity for grafting is determined at the time of injury. If the full thickness of skin has been destroyed nothing will restore its viability, and skin must be applied if deformity is to be avoided. By the limitation of infection, however, and the strict avoidance of anything which will cause further injury to damaged tissues, the exposure method reduces the chance that a burn, which initially destroyed only part of the dermis, will be converted into one of full-thickness skin loss. Again, the exposure method is held by some to delay healing. I disagree. I believe that with the added control of infection the surviving islets of epithelium in deep dermal burns survive and eventually accomplish healing. Whether waiting is advisable in all such cases is questionable. In burns one of the major problems is the control of infection. Naturally, resort was made to antibiotics applied locally and administered systemically. Unfortunately, the use of antibiotics has become almost indiscriminate. I feel the time has come to ask whether we can omit antibiotics altogether or employ them in only the more extensive burns and in minor burns at any indication of sepsis. With patients on a four-hourly temperature check there is little chance of infections becoming severe. In the few burns I have treated (up to IO per cent. of the body surface) by exposure without antibiotics, the results have been good with no evidence of sepsis. Exposure of burns has been combined in most of our patients with antibiotic therapy. Penicillin was administered systemically as soon as possible, either intramuscularly or in the intravenous fluid, in a dosage of o. 5 megaunit in each twenty-four hours. Except in burns of the neck and burns of considerable extent, systemic penicillin was discontinued from the sixth day. The principles of exposure with immobilisation are relatively easy to fulfil in certain areas of the body and more difficult to apply in others. The deep burn should be considered separately. Regions characteristically straightforward in respect of treatment are the face, upper arm and forearm, front of trunk and abdomen, genitalia, buttocks and thighs, and back, and the more troublesome are the neck, circumferential burns of the trunk, and burns of the legs, hands, and fingers. The D e e p B u r n - - T h e problems of the deep burn are common to all methods of local treatment. Once drying has been achieved and infection thereby controlled, the treatment of the deep burn becomes the surgical problem of skin replacement. When to intervene depends on many factors, of which the first is the consideration of the patient as a whole rather than consideration of the injury.
BURNS
227
There is no doubt that the maxim of skin coverage at the earliest possible moment is the ideal aim, but, except under expert hands, few children and few elderly patients will tolerate extensive excision and grafting at less than two to three weeks after a severe injury. Should the general condition of the patient be good, the burn deep, and the surgeon experienced in grafting, excision and cover can with advantage be carried out in seven to ten days from time of injury. In deep burns, say with both lower extremities completely involved, excision and grafting might have to be done at the tenth day to allow the second leg to be done by the twenty-first day. Team work is essential. A further problem is the difficulty of diagnosing the depth of injury in the early stages ; if excision is carried out earlier than the eighteenth day, then undoubtedly one runs the risk of excising areas where the dermis is only partially destroyed and which would have healed spontaneously had a more conservative policy been followed. On culture, the semi-fluid layer which forms under the crust covering burns, with destruction of skin but not of fat, is from time to time found to be contaminated by the coliform group of organisms, but these are judged to be of an attenuated strain and of low virulence because of the absence of fever and the relatively healthy state of the granulating surface when this milky material is gently wiped away and because of the success of immediate grafting. The receptiveness of a raw surface fails from the time of injury and, in our experience, it is infinitely preferable to graft as early as possible in the presence of bacteriological evidence of infection than to spend valuable weeks in trying to sterilise the surface. When grafting is judged advisable, the area of crusting removed depends on the total surface area of the crust and on the skin available for cover ; the use of homografts must be considered. There is no doubt at all that the ideal in deep burns treated by exposure is excision of the complete crust with immediate skin coverage, either autograft, autograft and homograft, or homograft. To leave an area uncovered is to invite infection. Leaving out the possibility of immediate excision, the cover sequence in burns should be crust, then skin, whether the burn be superficial or deep, and there should never be a raw surface. One of the urgent necessities to-day is the training of teams to carry out extensive rapid excision and immediate skin coverage. Bleeding is controlled by temporary pressure. The mixed superficial and deep burn has particular problems. The crust covering both the deep dermal injury and the deep burn tends to remain adherent. Frequently, when removing the crust about the eighteenth day in deep dermal burns, one tends to damage the new epithelial covering layer. Postponement of removal of the crust to allow further healing of the deep dermal section of the burn might lead to disregard of the optimum time for grafting of the deep section of the burn, and the healing process in such a burn might drag on for three to four weeks. On occasion, deep dermal burns are best considered as deep burns, and if the general condition of the patient be satisfactory, excision and grafting are carried out early. In our unit the overall average time for excision and grafting has been the sixteenth day from the time of the injury. The grafts are applied preferably in sheets or strips ; if in postage-stamp sizes they must be close together. The first dressing is removed on the third or fourth day and, where possible, the grafts are exposed throughout each day and covered at night. Exposure at this stage by drying and cooling counters the effect of surface proteolytic enzymes. On occasion
228
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
the exposure method has been successfully carried right through the grafting period. I find it difficult to state the circumstances which indicate early exposure of grafts. At the moment various forms of nylon covers are employed in place of tulle gras in an attempt to keep the surface cool and to diminish the danger of maceration and digestion. In the past few months a Series of deep burns have given added food for thought. I. A boy of 3 was admitted with infected deep burns of the buttocks and lower extremities on the twelfth day following injury. The burns were exposed for one week in an attempt to limit the toxic absorption. This was only partially successful. Following excision of skin and all the underlying fat which appeared pale and in parts liquefied, and immediate total covering with homograft and autograft, there was marked improvement in the child's general condition within a few hours. 2 and 3. A young man of 19 and a youth of 15, both with extensive deep circumferential burns of the lower trunk and lower extremities, forearms, and hands, were seen for the first time on the twenty-first day following injury. The burnt surfaces had been treated by exposure. The lad of 19 was semi-comatose, with poor peripheral circulation, and was thought by his surgeon to have no chance of survival. I concurred. The lad of 15 was in moderate condition : temperature moderately elevated; appetite good; pulse from the first had been fast. He presented a real problem in skin cover. The point of great interest with this boy, however, was the improvement in his condition which followed the excision of the burnt skin and the partially liquefied underlying fat, and immediate coverage with autograft and homograft. The young man of' 19 who was semi-comatose was taken to the theatre, and as a last resort the more involved leg was amputated through mid-thigh. This was followed by dramatic improvement in his general condition. 4. A man of 55 years with deep burns of the buttock and left lower extremity was seen for the first time five and a half weeks after injury. The treatment of the burn surface had been by exposure. There was, in distinction to the other cases, not even a mild elevation of temperature. At the time of excision it was found that all the fat had been coagulated and there were no areas of liquefaction. The three patients with burns demonstrating destruction of skin and involvement of fat showed degrees of intoxication passing in the most severe to semi-coma. Locally the burns could be considered at the worst moderately infected, but certainly not sufficiently so to warrant such intoxication. The man with the burn demonstrating both destruction of skin and fat in the involved area showed no intoxication. In the three patients, following total excision of the partially involved subcutaneous tissue, there was very rapid improvement, with decreased intoxication and in the most severe case recovery of consciousness. What the nature of the toxic agent is I am not at the moment prepared to say nor do I know its oath of absorption ; with total excision, all channels of lymphatic absorption are removed. To avoid such pictures in deep burns with partial involvement of fat, the essential points in care are immobilisation, cooling, and excision as soon after seven to ten days as possible. Again one must stress the absolute value of organised team work in such
BURNS
229
extreme cases. One shudders to think of the almost unmanageable problem of mass casualties with many extensive deep burns. The problems in burn treatment are many and require observations in the wards over long periods. The closer one can keep within the normal biological responses to injury the better would appear to be the results. CONCLUSIONS In my opinion, the exposure method has afforded increased control of infection in burns. The patients have been more comfortable and the healing time, in superficial burns, has not been increased. I believe that by exposure, with the resultant drying and cooling, the deleterious effect of proteolytic digests has been considerably reduced. The ana:mia and hypoproteimemia which characterise the healing stage of an extensive deep burn have been singularly absent. This is confirmed in some measure by the maintained high blood hremoglobin and protein levels, but more reliably by the general appearance and good nutrition of the patients. The aim in the local care of burns is to encourage the early formation of a dry crust. This crust must be followed by skin cover, without the occurrence of an intervening raw surface. In superficial burns this is accomplished by natural healing, in deep burns by excision and grafting. The timing of this surgical interference should be governed by the general condition of the patient, but should be as early as possible and accomplished by the third week from receipt of the burn. Skin cover must be complete. If autograft is not adequate, homograft must be available. Surgical teams must be trained to excise deep burns and to cover immediately with skin, the whole procedure to be accomplished in as short a time as possible. The exposure method, properly controlled, is a " closed " method of treating burns. The absorptive or pressure dressing method, properly controlled, is a " closed " method, but if allowed to become and remain moist, is " open."
3[nd¢ on;[ Prin/e~/ in (;rent l~ri/a/n ~/ Tltl,. ])AR~X I>R):~ ],~r~., ~dlnburs]~
By A. B. WALLACE, M.Sc., F.R.C.S.Ed.
Lecturer in Plastic Surgery, University of Edinburgh MY first article on the treatment of burns appeared twelve years ago. From the first I held that there was no one method in local care. I still subscribe to that view ; I have never wavered, but I should now like to extend it. No one method of local care has all the answers ; no one person has all the answers ; no one unit has all the answers. I do not propose to describe the exposure method in detail, nor to give the detailed treatment of separate regions--rather should I prefer to be provocative in certain directions. The principles in local care as I see them are : J I. To make the burnt area unfavourable for the growth and multiplication of organisms. 2. To reduce the invasiveness of surface organisms by avoiding moist applications and any but bland antiseptics, by keeping the part cool and immobile, and by strict nursing care. Where possible, oedema should be limited by elevating the affected part. 3. To control infection by antibiotic therapy. At the moment I think it is advisable to continue antibiotic therapy administered systemically, not locally. Yet I must express the thought that if a method of local treatment were adequate, even systemic penicillin would be unnecessary or necessary for only a few days. Methods completely dependent on an antibiotic umbrella or shield are bound sooner or later to run into trouble. In first-aid I strongly advocate the teaching of elevation of the affected part. Exposure of a burn to the air is by no means a new procedure. In its present-day form this method of treatment involves the administration of penicillin systemically, full exposure and elevation of the affected part with as much immobilisation as is practicable, and abstention from all local irritants and any form of local heating. From time to time I am told of burns treated by exposure that have gone wrong ; even the Ps. pyocyanea, which I have never found, has caused trouble. Where investigation has been possible, the local treatment has commonly been moribund inactivity and the general care lively activity. For instance, involved hands have been nursed dependent, and burnt children have been permitted to romp about the bed or be fondled by visiting parents. As with despised tannic acid, the dangers of cracks in the crust have been fully publicised. I have not found cracks to give trouble. Most are undoubtedly the result of inadequate support. In general, the more simple and elementary that principles are, the greater is the tendency to fail in their observance. * Read at a meeting of the British Association of Plastic Surgeons, Edinburgh, on 8th September I95I. 224
BURNg
225
T h e early formation o f a scab is o f paramount importance, for it protects the wound against the entrance o f pathogenic organisms, provides a framework or scaffold for young epithelium, and in deep burns presents a barrier to the loss of protein, salt, and red blood cells until it is excised and replaced with a skin graft. Nothing must be done either to delay its early formation or to disturb its integrity. In superficial burns the crust separates within three weeks and leaves a healed surface; in deep burns, w i t h i n the same interval, sloughs must be excised and skin grafts applied to the areas o f skin loss. On several occasions I have pointed out the close relationship between the so-called " pressure dressing " and " e x p o s u r e " methods. Once again I deprecate the misuse o f the term " pressure " and strongly advocate the term " absorptive dressings." T h e two forms of treatment, " absorptive dressings " and " exposure," far from being distinct as the terms " open " and " closed " sometimes applied to them would suggest, are in fact closely related and, what is more, interchangeable. Local applications preventing absorption do harm. I am very conscious o f the so-called" open " and " closed " schools of thought. T h e exposure method is commonly included under the " o p e n " school, and yet the dry crust after forty-eight hours is the most perfect " closed " dressing possible apart from living skin. T h e absorptive or pressure dressing when it becomes moist and when for one reason or another evaporation is not possible, is " open " to any and all contaminants on the covering bandages and bed-clothes. I hold that the " e x p o s u r e " method is more " c l o s e d " than even the absorptive dressing, as the surface dries quicker. I f the relationship between the two methods and the value o f each were fully appreciated, discussion would become more constructive than destructive. Some members o f American burn units in humid climes have expressed concern that exposed burn surfaces take five or even six days to crust. I can best meet this criticism by quoting from a recent letter from Lt.-Col. A. Whyte, R.A.M.C. Military Hospital, F a y i d : " We have had numerous and extensive burns treated by exposure and not a failure. M y impression is that drying and healing are quicker here. Humidity has been high the last six weeks, but a fan blowing on the burned areas has helped drying and kept flies away. Flies are a menace, but do no harm on dry scabs. Burns during the fly season we have nursed in side wards, which, being small, can be repeatedly D . D . T . sprayed and flies so controlled. I was able to confound the prophets. T h e y said exposure cannot work in sandstorms. One o f the worst cases we have had came through a three-day sandstorm and never turned a hair. T h e great advantage o f no dressings at all on burns under hot weather conditions has to be experienced to be believed. It is a crowning mercy indeed. Exposure may not be the answer to all cases, but we still have to see a failure, even under the conditions of this climate." T h e application o f biological fluids has been suggested to hasten crusting. This would at first sight appear beneficial as the earlier a dry crust forms the sooner is infection controlled. On the other hand, the escape of plasma does decompress the cedematous dermis, and must be o f considerable relief to the dermal vessels and dermal cells in dermo-epidermal burns. I would therefore advise caution with the application o f local coagulants till the optimum time for crusting is known. In my burns unit, cleansing is often done under inhalation anaesthesia (cyclopropane), which can be considered a form o f sedation. T h e burnt area is cleansed with I per cent. cetrimide or isotonic saline: blisters are snipped and
226
BRITISH
JOURNAL
OF PLASTIC
SURGERY
raised epidermis is removed. The burnt surface is then gently dried with gauze. Dusting of the involved part with a powder consisting of lactose, with the addition of io,ooo International Units of calcium penicillin per gramme, has been carried out in a large series, but I consider its local application might be omitted. If it is used locally the powder is insufflated over the burnt surface every four hours until the surface is dry (usually for forty-eight hours). Pain has not been a prominent feature. All manner of organisms fall on the burn, but they do no harm. Ps. pyocyanea and Proteus vulgaris have been grown on culture plates placed beside burnt surfaces, but have never infected the burns. One question is frequently asked: Does the exposure method of treatment increase or decrease the necessity for grafting ? What is seldom appreciated is that the necessity for grafting is determined at the time of injury. If the full thickness of skin has been destroyed nothing will restore its viability, and skin must be applied if deformity is to be avoided. By the limitation of infection, however, and the strict avoidance of anything which will cause further injury to damaged tissues, the exposure method reduces the chance that a burn, which initially destroyed only part of the dermis, will be converted into one of full-thickness skin loss. Again, the exposure method is held by some to delay healing. I disagree. I believe that with the added control of infection the surviving islets of epithelium in deep dermal burns survive and eventually accomplish healing. Whether waiting is advisable in all such cases is questionable. In burns one of the major problems is the control of infection. Naturally, resort was made to antibiotics applied locally and administered systemically. Unfortunately, the use of antibiotics has become almost indiscriminate. I feel the time has come to ask whether we can omit antibiotics altogether or employ them in only the more extensive burns and in minor burns at any indication of sepsis. With patients on a four-hourly temperature check there is little chance of infections becoming severe. In the few burns I have treated (up to IO per cent. of the body surface) by exposure without antibiotics, the results have been good with no evidence of sepsis. Exposure of burns has been combined in most of our patients with antibiotic therapy. Penicillin was administered systemically as soon as possible, either intramuscularly or in the intravenous fluid, in a dosage of o. 5 megaunit in each twenty-four hours. Except in burns of the neck and burns of considerable extent, systemic penicillin was discontinued from the sixth day. The principles of exposure with immobilisation are relatively easy to fulfil in certain areas of the body and more difficult to apply in others. The deep burn should be considered separately. Regions characteristically straightforward in respect of treatment are the face, upper arm and forearm, front of trunk and abdomen, genitalia, buttocks and thighs, and back, and the more troublesome are the neck, circumferential burns of the trunk, and burns of the legs, hands, and fingers. The D e e p B u r n - - T h e problems of the deep burn are common to all methods of local treatment. Once drying has been achieved and infection thereby controlled, the treatment of the deep burn becomes the surgical problem of skin replacement. When to intervene depends on many factors, of which the first is the consideration of the patient as a whole rather than consideration of the injury.
BURNS
227
There is no doubt that the maxim of skin coverage at the earliest possible moment is the ideal aim, but, except under expert hands, few children and few elderly patients will tolerate extensive excision and grafting at less than two to three weeks after a severe injury. Should the general condition of the patient be good, the burn deep, and the surgeon experienced in grafting, excision and cover can with advantage be carried out in seven to ten days from time of injury. In deep burns, say with both lower extremities completely involved, excision and grafting might have to be done at the tenth day to allow the second leg to be done by the twenty-first day. Team work is essential. A further problem is the difficulty of diagnosing the depth of injury in the early stages ; if excision is carried out earlier than the eighteenth day, then undoubtedly one runs the risk of excising areas where the dermis is only partially destroyed and which would have healed spontaneously had a more conservative policy been followed. On culture, the semi-fluid layer which forms under the crust covering burns, with destruction of skin but not of fat, is from time to time found to be contaminated by the coliform group of organisms, but these are judged to be of an attenuated strain and of low virulence because of the absence of fever and the relatively healthy state of the granulating surface when this milky material is gently wiped away and because of the success of immediate grafting. The receptiveness of a raw surface fails from the time of injury and, in our experience, it is infinitely preferable to graft as early as possible in the presence of bacteriological evidence of infection than to spend valuable weeks in trying to sterilise the surface. When grafting is judged advisable, the area of crusting removed depends on the total surface area of the crust and on the skin available for cover ; the use of homografts must be considered. There is no doubt at all that the ideal in deep burns treated by exposure is excision of the complete crust with immediate skin coverage, either autograft, autograft and homograft, or homograft. To leave an area uncovered is to invite infection. Leaving out the possibility of immediate excision, the cover sequence in burns should be crust, then skin, whether the burn be superficial or deep, and there should never be a raw surface. One of the urgent necessities to-day is the training of teams to carry out extensive rapid excision and immediate skin coverage. Bleeding is controlled by temporary pressure. The mixed superficial and deep burn has particular problems. The crust covering both the deep dermal injury and the deep burn tends to remain adherent. Frequently, when removing the crust about the eighteenth day in deep dermal burns, one tends to damage the new epithelial covering layer. Postponement of removal of the crust to allow further healing of the deep dermal section of the burn might lead to disregard of the optimum time for grafting of the deep section of the burn, and the healing process in such a burn might drag on for three to four weeks. On occasion, deep dermal burns are best considered as deep burns, and if the general condition of the patient be satisfactory, excision and grafting are carried out early. In our unit the overall average time for excision and grafting has been the sixteenth day from the time of the injury. The grafts are applied preferably in sheets or strips ; if in postage-stamp sizes they must be close together. The first dressing is removed on the third or fourth day and, where possible, the grafts are exposed throughout each day and covered at night. Exposure at this stage by drying and cooling counters the effect of surface proteolytic enzymes. On occasion
228
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
the exposure method has been successfully carried right through the grafting period. I find it difficult to state the circumstances which indicate early exposure of grafts. At the moment various forms of nylon covers are employed in place of tulle gras in an attempt to keep the surface cool and to diminish the danger of maceration and digestion. In the past few months a Series of deep burns have given added food for thought. I. A boy of 3 was admitted with infected deep burns of the buttocks and lower extremities on the twelfth day following injury. The burns were exposed for one week in an attempt to limit the toxic absorption. This was only partially successful. Following excision of skin and all the underlying fat which appeared pale and in parts liquefied, and immediate total covering with homograft and autograft, there was marked improvement in the child's general condition within a few hours. 2 and 3. A young man of 19 and a youth of 15, both with extensive deep circumferential burns of the lower trunk and lower extremities, forearms, and hands, were seen for the first time on the twenty-first day following injury. The burnt surfaces had been treated by exposure. The lad of 19 was semi-comatose, with poor peripheral circulation, and was thought by his surgeon to have no chance of survival. I concurred. The lad of 15 was in moderate condition : temperature moderately elevated; appetite good; pulse from the first had been fast. He presented a real problem in skin cover. The point of great interest with this boy, however, was the improvement in his condition which followed the excision of the burnt skin and the partially liquefied underlying fat, and immediate coverage with autograft and homograft. The young man of' 19 who was semi-comatose was taken to the theatre, and as a last resort the more involved leg was amputated through mid-thigh. This was followed by dramatic improvement in his general condition. 4. A man of 55 years with deep burns of the buttock and left lower extremity was seen for the first time five and a half weeks after injury. The treatment of the burn surface had been by exposure. There was, in distinction to the other cases, not even a mild elevation of temperature. At the time of excision it was found that all the fat had been coagulated and there were no areas of liquefaction. The three patients with burns demonstrating destruction of skin and involvement of fat showed degrees of intoxication passing in the most severe to semi-coma. Locally the burns could be considered at the worst moderately infected, but certainly not sufficiently so to warrant such intoxication. The man with the burn demonstrating both destruction of skin and fat in the involved area showed no intoxication. In the three patients, following total excision of the partially involved subcutaneous tissue, there was very rapid improvement, with decreased intoxication and in the most severe case recovery of consciousness. What the nature of the toxic agent is I am not at the moment prepared to say nor do I know its oath of absorption ; with total excision, all channels of lymphatic absorption are removed. To avoid such pictures in deep burns with partial involvement of fat, the essential points in care are immobilisation, cooling, and excision as soon after seven to ten days as possible. Again one must stress the absolute value of organised team work in such
BURNS
229
extreme cases. One shudders to think of the almost unmanageable problem of mass casualties with many extensive deep burns. The problems in burn treatment are many and require observations in the wards over long periods. The closer one can keep within the normal biological responses to injury the better would appear to be the results. CONCLUSIONS In my opinion, the exposure method has afforded increased control of infection in burns. The patients have been more comfortable and the healing time, in superficial burns, has not been increased. I believe that by exposure, with the resultant drying and cooling, the deleterious effect of proteolytic digests has been considerably reduced. The ana:mia and hypoproteimemia which characterise the healing stage of an extensive deep burn have been singularly absent. This is confirmed in some measure by the maintained high blood hremoglobin and protein levels, but more reliably by the general appearance and good nutrition of the patients. The aim in the local care of burns is to encourage the early formation of a dry crust. This crust must be followed by skin cover, without the occurrence of an intervening raw surface. In superficial burns this is accomplished by natural healing, in deep burns by excision and grafting. The timing of this surgical interference should be governed by the general condition of the patient, but should be as early as possible and accomplished by the third week from receipt of the burn. Skin cover must be complete. If autograft is not adequate, homograft must be available. Surgical teams must be trained to excise deep burns and to cover immediately with skin, the whole procedure to be accomplished in as short a time as possible. The exposure method, properly controlled, is a " closed " method of treating burns. The absorptive or pressure dressing method, properly controlled, is a " closed " method, but if allowed to become and remain moist, is " open."
3[nd¢ on;[ Prin/e~/ in (;rent l~ri/a/n ~/ Tltl,. ])AR~X I>R):~ ],~r~., ~dlnburs]~