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PHOSPHORUS BURNS
202
PHOSPHORUS
BURNS
In more extensive, second degree, and severe burns, no attempt should be made to deal with the lesion. A pad
soaked in alkaline copper solution is applied, an intravenous serum transfusion given and the patient rushed to hospital ASSISTANT MEDICAL OFFICER OF HEALTH FOR FINSBURY for excision of affected tissues under an anaesthetic. PHOSPHORUS incendiary bombs are being used by the We have also for collapsible canvas baths for Germans, and it is fully appreciated by those responsible the mobile unit. In the event of an incident involving for organising civil defence that phosphorus may play serious phosphorus burns, the only hope for a phosphorus an important part should intensive raiding of this casualty would be immersion in such a bath and a serum country be resumed. Sticks of phosphorus are being transfusion before being sent to hospital. burned at fire demonstrations during ARP instruction. We have, in this borough, had first-hand experience of OF GROUPING SERUM relatively trifling first degree phosphorus burns suffered these wardens during demonstrations. R. A. SHOOTER, MB CAMB by In one case-the first—a burn of a finger resulted in LATE MEDICAL OFFICER, N.E. LONDON BLOOD SUPPLY DEPOT several weeks of incapacity with severe pain. At one THE of an ideal grouping serum are numerous stage it was decided that the finger would have to be but notqualities difficult to obtain. include rapidity of amputated. Though it was finally saved this incident action, usually connected withThey a high titre and absence taught us a lesson. Phosphorus burns, even minor of prozone phenomena, ability to react with weak or It ones, are more dangerous than most people realise. from freedom agglutinogens, subgroup rouleaux-forming may be useful, therefore, to set out the more important tendencies and from agglutinins other than those of the theoretical about and them. points practical ABO series, a low fat content and sterility. General Principles.-Phosphorus is lipoid soluble. While most writers insist on a high titre serum being It therefore spreads with great rapidity and tends to there is no agreement as to what is the lowest used, eat its way into the deeper tissues. Speed in treatment figure compatible with safety. Wiener (1939) states is therefore the first essential. Every first-aider must that a good serum will bring about visible agglutination be taught to soak the area burned with phosphorus in an in a dilution of 1/20, although he says later that for the alkaline copper solution with the minimum of delay. detection of the A2 receptor in a subgroup A2B a serum This solution combines with the phosphorus (in an of very high potency may be required. Taylor and alkaline medium copper phosphide is formed) and has others (1940)recommend a serum with a titre of at least the additional advantage of making the phosphorus 64, while preferring a higher one, and Riddell (1939) one easily visible ; all phosphorus spots show up as dead with a titre not less than 100. This discrepancy is white with a faint bluish tinge. The rapid removal of mainly due to the varying methods of titre estimations all affected tissues is of primary importance. Small in use. Most methods depend on the use of mixtures of ;spots which are restricted to the epidermis can be’rubbed increasing dilutions of serum with homologous cells, the away with pledgets of wool soaked in alkaline copper titre being the reciprocal of the serum dilution in the last solution. More extensive areas must be scraped with tube in which agglutination occurs. :a scalpel. The danger of shock is far greater than with Although simple in principle, at the moment estimaordinary burns. If areas of skin greater than 6 in. are tions of one laboratory cannot be compared with those involved, or if the burn is of second degree, immediate of another, and within one laboratory results in a series transfusion with serum or plasma may be a lifesaving of experiments may not be comparable. Three possible measure. variants are responsible for this. The saline of the cell Bearing these principles in mind, we have put the suspension may or may not be included in the calculation following policy into force. of the dilution. Some methods take the end point as the First-aid Treatment.—First-aiders are to be supplied last tube in which agglutination can be seen microscopicwith two bottles, one of alkali (about gr. 60 of sodium a,lly, others take macroscopic agglutination; this difference amounts to one or two tubes in a serial dilution. bicarbonate to the pint) and one of 2% copper sulphate solution. These solutions cannot be kept mixed, because Finally the sensitivity of the cells is a very variable an insoluble copper carbonate is formed which renders factor. INVESTIGATION the mixture useless. The solution should be mixed in a bowl in roughly equal quantities just before use. Nurses Four groups of titrations were carried out, the method in charge of first-aid posts and mobile units have been employed in each case, as in other titrations described in instructed to keep a phosphorus burn corner in the this paper, being that of Brewer (1937). A constant treatment room, equipped with the above solutions, amount of a measured 1/150 dilution in 0-85% sodium pledgets of cotton-wool and sterileVaseline ’ gauze. chloride of washed cells containing the homologous We have asked for a supply of amyl salicylate. The agglutinogen was added to increasing dilutions of serum corner is also equipped with scalpel, forceps, syringe, in 0.85% sodium chloride. The mixtures were made in procaine and standard serum transfusion kit for the use round-bottomed tubes of about 1 cm. diameter and the of the doctor. Nurses in charge are told to call a doctor readings were made after standing overnight at room if they are in doubt about the severity of any phosphorus temperature. The saline cell suspension was included in burn. They are only to treat slight, superficial burns, the calculation of the dilution of the serum. Before seen immediately, and to rub off all affected epidermis reading, the tubes were inverted twice and the agglutinawith pledgets soaked in the solution. It is explained tion was scored as follows : to them that dabbing is useless and that hard rubbing + + + One solid clump. is essential. Either gentian violet or vaseline gauze can + + Several small clumps or one - large clump with be applied if all traces of phosphorus have effectively several smaller ones. been removed. In all other cases they are instructed + Suspension of small but macroscopic clumps. to call the doctor of the post. t Very small but definite clumps detectable by the naked eye, possibly with the assistance of a hand Medical First-aid Treatment.-For the guidance of lens. first-aid post and mobile unit doctors, we have suggested No visible agglutination. the following treatment :In each group of titrations the same group A serum was In first degree phosphorus burns, where the area of skin titrated against 15 different group B cells. One protocol affected is too great to allow of removal by rubbing with pledgets, the affected skin is to be removed by scraping with typical of the four is shown in the table ; it illustrates the a scalpel after infiltration of a surrounding area with procaine. range of variation which may occur. The skin surface should then be dressed with amyl salicylate. To obtain comparable titre values end-point reading should be adjusted and calculation of the dilution made. This liquid has the advantages over other dressings that it It is suggested that the use of a cell suspension from a dulls pain, prevents scarring, and promotes granulation thus pool of 10 or-more bloods will give more even results not accelerating healing. All second degree burns, however small, should be treated only against group B cells but also against group A cells, where the use of cells from 10 or more bloods is likely to for shock. If all phosphorus can be excised at the post, avoid the presence of a predominant number of group A2 without difficulty, this should be done first, but 400 c.cm. of cells. dried serum solution are then to be injected intravenously.
EDGAR OBERMER,
M D LAUSANNE, M R C S
applied
PREPARATION
-
-
’
PHOSPHORUS
BURNS
In more extensive, second degree, and severe burns, no attempt should be made to deal with the lesion. A pad
soaked in alkaline copper solution is applied, an intravenous serum transfusion given and the patient rushed to hospital ASSISTANT MEDICAL OFFICER OF HEALTH FOR FINSBURY for excision of affected tissues under an anaesthetic. PHOSPHORUS incendiary bombs are being used by the We have also for collapsible canvas baths for Germans, and it is fully appreciated by those responsible the mobile unit. In the event of an incident involving for organising civil defence that phosphorus may play serious phosphorus burns, the only hope for a phosphorus an important part should intensive raiding of this casualty would be immersion in such a bath and a serum country be resumed. Sticks of phosphorus are being transfusion before being sent to hospital. burned at fire demonstrations during ARP instruction. We have, in this borough, had first-hand experience of OF GROUPING SERUM relatively trifling first degree phosphorus burns suffered these wardens during demonstrations. R. A. SHOOTER, MB CAMB by In one case-the first—a burn of a finger resulted in LATE MEDICAL OFFICER, N.E. LONDON BLOOD SUPPLY DEPOT several weeks of incapacity with severe pain. At one THE of an ideal grouping serum are numerous stage it was decided that the finger would have to be but notqualities difficult to obtain. include rapidity of amputated. Though it was finally saved this incident action, usually connected withThey a high titre and absence taught us a lesson. Phosphorus burns, even minor of prozone phenomena, ability to react with weak or It ones, are more dangerous than most people realise. from freedom agglutinogens, subgroup rouleaux-forming may be useful, therefore, to set out the more important tendencies and from agglutinins other than those of the theoretical about and them. points practical ABO series, a low fat content and sterility. General Principles.-Phosphorus is lipoid soluble. While most writers insist on a high titre serum being It therefore spreads with great rapidity and tends to there is no agreement as to what is the lowest used, eat its way into the deeper tissues. Speed in treatment figure compatible with safety. Wiener (1939) states is therefore the first essential. Every first-aider must that a good serum will bring about visible agglutination be taught to soak the area burned with phosphorus in an in a dilution of 1/20, although he says later that for the alkaline copper solution with the minimum of delay. detection of the A2 receptor in a subgroup A2B a serum This solution combines with the phosphorus (in an of very high potency may be required. Taylor and alkaline medium copper phosphide is formed) and has others (1940)recommend a serum with a titre of at least the additional advantage of making the phosphorus 64, while preferring a higher one, and Riddell (1939) one easily visible ; all phosphorus spots show up as dead with a titre not less than 100. This discrepancy is white with a faint bluish tinge. The rapid removal of mainly due to the varying methods of titre estimations all affected tissues is of primary importance. Small in use. Most methods depend on the use of mixtures of ;spots which are restricted to the epidermis can be’rubbed increasing dilutions of serum with homologous cells, the away with pledgets of wool soaked in alkaline copper titre being the reciprocal of the serum dilution in the last solution. More extensive areas must be scraped with tube in which agglutination occurs. :a scalpel. The danger of shock is far greater than with Although simple in principle, at the moment estimaordinary burns. If areas of skin greater than 6 in. are tions of one laboratory cannot be compared with those involved, or if the burn is of second degree, immediate of another, and within one laboratory results in a series transfusion with serum or plasma may be a lifesaving of experiments may not be comparable. Three possible measure. variants are responsible for this. The saline of the cell Bearing these principles in mind, we have put the suspension may or may not be included in the calculation following policy into force. of the dilution. Some methods take the end point as the First-aid Treatment.—First-aiders are to be supplied last tube in which agglutination can be seen microscopicwith two bottles, one of alkali (about gr. 60 of sodium a,lly, others take macroscopic agglutination; this difference amounts to one or two tubes in a serial dilution. bicarbonate to the pint) and one of 2% copper sulphate solution. These solutions cannot be kept mixed, because Finally the sensitivity of the cells is a very variable an insoluble copper carbonate is formed which renders factor. INVESTIGATION the mixture useless. The solution should be mixed in a bowl in roughly equal quantities just before use. Nurses Four groups of titrations were carried out, the method in charge of first-aid posts and mobile units have been employed in each case, as in other titrations described in instructed to keep a phosphorus burn corner in the this paper, being that of Brewer (1937). A constant treatment room, equipped with the above solutions, amount of a measured 1/150 dilution in 0-85% sodium pledgets of cotton-wool and sterileVaseline ’ gauze. chloride of washed cells containing the homologous We have asked for a supply of amyl salicylate. The agglutinogen was added to increasing dilutions of serum corner is also equipped with scalpel, forceps, syringe, in 0.85% sodium chloride. The mixtures were made in procaine and standard serum transfusion kit for the use round-bottomed tubes of about 1 cm. diameter and the of the doctor. Nurses in charge are told to call a doctor readings were made after standing overnight at room if they are in doubt about the severity of any phosphorus temperature. The saline cell suspension was included in burn. They are only to treat slight, superficial burns, the calculation of the dilution of the serum. Before seen immediately, and to rub off all affected epidermis reading, the tubes were inverted twice and the agglutinawith pledgets soaked in the solution. It is explained tion was scored as follows : to them that dabbing is useless and that hard rubbing + + + One solid clump. is essential. Either gentian violet or vaseline gauze can + + Several small clumps or one - large clump with be applied if all traces of phosphorus have effectively several smaller ones. been removed. In all other cases they are instructed + Suspension of small but macroscopic clumps. to call the doctor of the post. t Very small but definite clumps detectable by the naked eye, possibly with the assistance of a hand Medical First-aid Treatment.-For the guidance of lens. first-aid post and mobile unit doctors, we have suggested No visible agglutination. the following treatment :In each group of titrations the same group A serum was In first degree phosphorus burns, where the area of skin titrated against 15 different group B cells. One protocol affected is too great to allow of removal by rubbing with pledgets, the affected skin is to be removed by scraping with typical of the four is shown in the table ; it illustrates the a scalpel after infiltration of a surrounding area with procaine. range of variation which may occur. The skin surface should then be dressed with amyl salicylate. To obtain comparable titre values end-point reading should be adjusted and calculation of the dilution made. This liquid has the advantages over other dressings that it It is suggested that the use of a cell suspension from a dulls pain, prevents scarring, and promotes granulation thus pool of 10 or-more bloods will give more even results not accelerating healing. All second degree burns, however small, should be treated only against group B cells but also against group A cells, where the use of cells from 10 or more bloods is likely to for shock. If all phosphorus can be excised at the post, avoid the presence of a predominant number of group A2 without difficulty, this should be done first, but 400 c.cm. of cells. dried serum solution are then to be injected intravenously.
EDGAR OBERMER,
M D LAUSANNE, M R C S
applied
PREPARATION
-
-
’