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The history of the classification of burns (diagnosis of depth)
THE HISTORY OF THE CLASSIFICATION OF BURNS (DIAGNOSIS OF DEPTH) By Lieut.-Colonel A. V. FORAGE, R.A.M.C., Ch.M., F.R.C.S.
Military Hospital, Colchester, Essex UNTIL gunpowder was used on any great scale, the subject of burns had little place in surgical literature. Guy de Chauliac (I363) does not mention gunshot wounds or burns at all. Even though no attempt was made to classify burns formally, early writers like Jean de Vigo (i483) advised treatment according to severity and not according to the manner of burning. He wrote : " Sometime the burning of fire is slight and in the overmost part of the skinne, and produceth only little blisters ; sometimes it is deepe and bumeth the muscles." It is of interest that he advised the use of applications which " digest" the eschar. T h e first attempt to classify burns is generally attributed to Fabry (Guilielmi Hildani Fabricii, I6IO), but Peter Lowe (I597) divided burns into superficial, average, and great. " T h e superficial are subject to Inflammation, the great ones to excoriation and exulceration, those which are meane have little blisters on the skinne." These undoubtedly correspond to erythema, vesication, and healing by granulation. Fabricius (I6rO) divided burns into three grades or types and an important aspect of his writings is the attention he paid to the temperature and duration of contact between the causative agent and the skin. His classification is as follows : First Degree : Stinging pain, erythema going on to vesication. Second Degree : Immediate swelling and blistering. Third Degree : " T h e skin is black and if it is pricked with a scalpel it feels tough . . . and when it falls off a deep rotting ulcer is left." Wiseman (I719) also divided burns into three degrees. Superficial burns were recognised by vesication, deeper ones by eschar formation, and the deepest ones involved muscle and led to contractures. He describes how he burnt his thumb and fingers when the turpentine with which he was treating a patient was set alight by a candle flame. He noticed that the superficial burn was very painful and the finger which was burnt to an eschar was relatively painless. Van Swieten (i745) , quoting Boerhaave, writes that burns of slight degree were those which were followed by " o n l y a slight redness and painful tumour of the skin with few or no blisters, or if any, they did not arise immediately after the burn and are full of limpid water." A more serious degree of burning would be known by " i t s more virulent cause, or its longer continuance of pain and the sudden appearance of blisters full of a yellow liquor immediately after burning, followed with a tensity or rigidity of the skin around the burnt part. But in the worst kind of burning, where all the vessels are suddenly destroyed, there do not appear any blisters in the burnt part itself, but there are blisters very often arise in its circumference, the skin turning livid, or sometimes quite black, but gives no sign of any sense of pain although cut or punctured by the scalpel, being quite hard and dry." 239
240
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Boerhaave, however, who believed that treatment should vary with depth, must have had considerable difficulty in diagnosing the depth of burns, for when he burnt his face and hands the resulting a~dema forced him to practise the most drastic treatments on himself. In the words of Van Swieten, " h e immediately ordered himself to be bled ad deliquim and the next day caused the vcnesecfion to be repeated and afterwards took a pretty strong purgative although he had been rendered nearly to a state of fainting by the slighter purgatives. He took care to have his face anointed only with Unguentum Nutritum and covered with Emplastrum ex Lapide Calaminari." There can be little doubt that these burns were superficial as " t h e cure of this dangerous scald was so happily advanced in eight or nine days, that he was able to appear again in public." This would suggest that superficial burns will heal in spite of any drastic treatment to which they, or the whole body, might be subjected ! Heister (I743) described the extravasation of fluid and red cells from the vessels in burns and he recognised four degrees of burning : First Degree : Early vesicafion and delayed onset of pain. Second Degree : Immediate severe pain and vesication. Third Degree : The common integuments and subjacent flesh form a crust. Fourth Degree : Total destruction to bone. Richter (i799) stated that the depth of burning depended not only upon the time temperature relationship of thermal injury, but also upon the susceptibility of the burnt part. He realised that there were " a s many degrees of burns as there are conceivable degrees of inflammation," but classified them into four main groups : Group I : Erythema without swelling. There is a sensation of burning : no systemic reaction in the form of pyrcxia. Group II : Erythema, swelling, and pyrexia, accompanied by severe pain. Group I I I : Immediate or gradual onset of vesication with severe pain and high pyrexia. Group IV: " . . . The burnt part is quite insensitive and dead . . . . It is dry after a dry burn, but after a moist burn it is usually moist." His association of systemic disturbances in proportion to the degree of burning is interesting. Dupuytren's (I832) classification of burns into six degrees is regarded as a classic. They are as follows : First Degree : Erythema without vesication. Second Degree: Vesicle formation and loss of epidermis with the signs of inflammation. Third Degree : Destruction of the papillary layer of the dermis. Fourth Degree : Destruction of the whole dermis to the subcutaneous tissue. Fifth Degree : " T h e formation of eschars of all the superficial parts and of the muscles to a greater or less distance from the bone." Sixth Degree : Carbonisation of the whole limb. He does not say how groups three and four are diagnosed, but one assumes that they are recognised from the course of the burn. Rust (I835) suggested four grades of burning which are also recommended by Bichat, Chelius, and Calissen (quoted by Sonnenburg and Tschmarke, I915).
THE
HISTORY
OF
THE
CLASSIFICATION
OF
BURNS
24I
In 1885 Boyer and Ginnard suggested the three degrees of burning which still survive with slight modifications in many parts of the world, viz., redness, blistering, and eschar formation. To this classification Sonnenburg and Tschmarke (1915) suggested that carbonisation be added as a fourth degree, but go on to state that this form of burn is of less interest clinically than it is pathologically or medico-legally as it automatically presumes prolonged contact with flames because the victim is unable to escape from the fire. In 1943 Clowes, Lund, and Levenson described the classification they used for 292 cases of burns which they treated. In this group, second degree burns were covered with small blisters, slight oedema, and a weeping surface ; a pink discoloration of the corium completed the picture. In third-degree burns, the appearances were those of charring, dry dead white dermis, or a brownish leathery appearance without aedema below it. Those burns which could not be diagnosed according to their early appearances were diagnosed according to the course they took. Converse and Robb-Smith (I944) suggested that burns should be classified on an anatomical basis and they described burns as superficial (partial skin loss), deep (total skin loss), and mixed. Jackson (1953) further subdivided partial skin loss burns into superficial partial skin loss (sup. p.s.1.) in which healing took place rapidly from hair follicles or epidermal remnants, and deep partial skin loss (deep p.s.1.) in which healing occurred slowly from epithelial islets derived from sweat glands or the bases of hair follicles in the subdermal fat domes. He describes the naked-eye appearances of sweat-duct healing.
COMMENT
Without doubt, a fairly accurate estimate can be made of the relative depths of an exposed burn, by observation of the varying superficial appearances over it. The superficial appearances of burns are in a perpetual state of change from the time that the burn is first inflicted until about the fifth day. Therefore a single inspection of the burnt surface is often unlikely to give an accurate clue to the depth of burning when it is carried out within a few hours of the injury. Repeated inspection and recording of superficial appearances is much more rewarding diagnostically. Terminology provides another source of error. It is suggested that the term " e r y t h e m a " be restricted to a red burn which blanches on pressure. " Stasis " should be used to describe red burns which do not blanch. The term stasis under these circumstances would include those appearances which are due to both stagnation and extravasation of blood. Burns which blanch on pressure eighteen hours after infliction are almost certain to be superficial partial skin loss injuries. Burns in which " stasis " is present immediately or within an hour after burning are almost certain to require grafting. The aim in modern treatment, once the shock phase of burns is overcome, is to achieve epithelial cover of the burnt surface as quickly as possible by natural means or by skin grafting. Therefore, most surgeons, while not actually committing themselves to paper, use the simple device of classifying burns as superficial or deep--the terminology used by Jean de Vigo in I483 !
242
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
REFERENCES BOYER, J., and GINNARD, L. (1885). " Etudes et Recherches Expdrimentales sur les Brfilures." Paris. DE CHAULIAC, GUY (1363). " On Wounds and Fractures." Translated and published by W. A. Brennan, Chicago, 1923 . CLOWES, G. H. A., jun., LUND, C. C., and LEVENSON, S. M. (1943). Ann. Surg., ziS, 761. CLOWES, W. (1591). " A Prooved Practise for all Young Chirurgians concerning Burnings with Gun-powder and Wounds made with Gunshot . . . " London : Wydow Broome. COCKSHOT, W. (1956). Surg. Gynec. Obstet., xo2, 116. CONVERSE, J. M., and ROBB-SMITH, A. H. T. (1944). Ann. Surg., I2O, 873. DUPUYTREN, BARON (1832). " Lemons Orales de Clinique Chirurgicale," vol. I. Paris. FABRICIUS, G. (161o). De Combustionibus. In " Uffenbach's Thesaurus Chirurgiae~" p. 1144. Frankfurt. HEISTER, L. (1743). " Of Burns and Scalds : A General System of Surgery," p. 22o. London. JACKSON, D. M. (1953). Brit..7. Surg., 4 o, 588. LOWE, PETER (I597). " The Whole Course of Chirurgie." London. RICHTER, A. G. (1799). "Anfangsgrtinde der Wundarzneykunst," vol. I, p. II~. G6ttingen. RUST, J. N. (1835). Aufsfitze und Abhandlungen aus dem Gebeite der Medizin. In " Schrnidt's Jahrbiicher," vol. 5, P. 337. SHEDD, D. P. (1958). Surgery, 43, IO24. SONNENBURG,E., and TSCHMARXE,P. (1915). Neue dtsch. Chit., I7, I. VAN SWlETEN, G. (1745). " The Commentaries upon the Aphorisms of Dr Herman Boerhaave (late Professor of Physics, University of Leyden)," vol. 4. London. DE VIGO, JEAN (1483). " The Whole Works of that famous Chirurgeon master John Vigo ; Newly corrected by menne skilfull in that Arte." Completed and published by Thomas Gale~ M.Ch., London, 1582. WISEMAN, R. (1719). Treatise VI : " A n Appendix to the Treatise of Gunshot Wounds." Eight Chirurgical Treatises. London.
Submitted for publication, July i96z.
Military Hospital, Colchester, Essex UNTIL gunpowder was used on any great scale, the subject of burns had little place in surgical literature. Guy de Chauliac (I363) does not mention gunshot wounds or burns at all. Even though no attempt was made to classify burns formally, early writers like Jean de Vigo (i483) advised treatment according to severity and not according to the manner of burning. He wrote : " Sometime the burning of fire is slight and in the overmost part of the skinne, and produceth only little blisters ; sometimes it is deepe and bumeth the muscles." It is of interest that he advised the use of applications which " digest" the eschar. T h e first attempt to classify burns is generally attributed to Fabry (Guilielmi Hildani Fabricii, I6IO), but Peter Lowe (I597) divided burns into superficial, average, and great. " T h e superficial are subject to Inflammation, the great ones to excoriation and exulceration, those which are meane have little blisters on the skinne." These undoubtedly correspond to erythema, vesication, and healing by granulation. Fabricius (I6rO) divided burns into three grades or types and an important aspect of his writings is the attention he paid to the temperature and duration of contact between the causative agent and the skin. His classification is as follows : First Degree : Stinging pain, erythema going on to vesication. Second Degree : Immediate swelling and blistering. Third Degree : " T h e skin is black and if it is pricked with a scalpel it feels tough . . . and when it falls off a deep rotting ulcer is left." Wiseman (I719) also divided burns into three degrees. Superficial burns were recognised by vesication, deeper ones by eschar formation, and the deepest ones involved muscle and led to contractures. He describes how he burnt his thumb and fingers when the turpentine with which he was treating a patient was set alight by a candle flame. He noticed that the superficial burn was very painful and the finger which was burnt to an eschar was relatively painless. Van Swieten (i745) , quoting Boerhaave, writes that burns of slight degree were those which were followed by " o n l y a slight redness and painful tumour of the skin with few or no blisters, or if any, they did not arise immediately after the burn and are full of limpid water." A more serious degree of burning would be known by " i t s more virulent cause, or its longer continuance of pain and the sudden appearance of blisters full of a yellow liquor immediately after burning, followed with a tensity or rigidity of the skin around the burnt part. But in the worst kind of burning, where all the vessels are suddenly destroyed, there do not appear any blisters in the burnt part itself, but there are blisters very often arise in its circumference, the skin turning livid, or sometimes quite black, but gives no sign of any sense of pain although cut or punctured by the scalpel, being quite hard and dry." 239
240
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Boerhaave, however, who believed that treatment should vary with depth, must have had considerable difficulty in diagnosing the depth of burns, for when he burnt his face and hands the resulting a~dema forced him to practise the most drastic treatments on himself. In the words of Van Swieten, " h e immediately ordered himself to be bled ad deliquim and the next day caused the vcnesecfion to be repeated and afterwards took a pretty strong purgative although he had been rendered nearly to a state of fainting by the slighter purgatives. He took care to have his face anointed only with Unguentum Nutritum and covered with Emplastrum ex Lapide Calaminari." There can be little doubt that these burns were superficial as " t h e cure of this dangerous scald was so happily advanced in eight or nine days, that he was able to appear again in public." This would suggest that superficial burns will heal in spite of any drastic treatment to which they, or the whole body, might be subjected ! Heister (I743) described the extravasation of fluid and red cells from the vessels in burns and he recognised four degrees of burning : First Degree : Early vesicafion and delayed onset of pain. Second Degree : Immediate severe pain and vesication. Third Degree : The common integuments and subjacent flesh form a crust. Fourth Degree : Total destruction to bone. Richter (i799) stated that the depth of burning depended not only upon the time temperature relationship of thermal injury, but also upon the susceptibility of the burnt part. He realised that there were " a s many degrees of burns as there are conceivable degrees of inflammation," but classified them into four main groups : Group I : Erythema without swelling. There is a sensation of burning : no systemic reaction in the form of pyrcxia. Group II : Erythema, swelling, and pyrexia, accompanied by severe pain. Group I I I : Immediate or gradual onset of vesication with severe pain and high pyrexia. Group IV: " . . . The burnt part is quite insensitive and dead . . . . It is dry after a dry burn, but after a moist burn it is usually moist." His association of systemic disturbances in proportion to the degree of burning is interesting. Dupuytren's (I832) classification of burns into six degrees is regarded as a classic. They are as follows : First Degree : Erythema without vesication. Second Degree: Vesicle formation and loss of epidermis with the signs of inflammation. Third Degree : Destruction of the papillary layer of the dermis. Fourth Degree : Destruction of the whole dermis to the subcutaneous tissue. Fifth Degree : " T h e formation of eschars of all the superficial parts and of the muscles to a greater or less distance from the bone." Sixth Degree : Carbonisation of the whole limb. He does not say how groups three and four are diagnosed, but one assumes that they are recognised from the course of the burn. Rust (I835) suggested four grades of burning which are also recommended by Bichat, Chelius, and Calissen (quoted by Sonnenburg and Tschmarke, I915).
THE
HISTORY
OF
THE
CLASSIFICATION
OF
BURNS
24I
In 1885 Boyer and Ginnard suggested the three degrees of burning which still survive with slight modifications in many parts of the world, viz., redness, blistering, and eschar formation. To this classification Sonnenburg and Tschmarke (1915) suggested that carbonisation be added as a fourth degree, but go on to state that this form of burn is of less interest clinically than it is pathologically or medico-legally as it automatically presumes prolonged contact with flames because the victim is unable to escape from the fire. In 1943 Clowes, Lund, and Levenson described the classification they used for 292 cases of burns which they treated. In this group, second degree burns were covered with small blisters, slight oedema, and a weeping surface ; a pink discoloration of the corium completed the picture. In third-degree burns, the appearances were those of charring, dry dead white dermis, or a brownish leathery appearance without aedema below it. Those burns which could not be diagnosed according to their early appearances were diagnosed according to the course they took. Converse and Robb-Smith (I944) suggested that burns should be classified on an anatomical basis and they described burns as superficial (partial skin loss), deep (total skin loss), and mixed. Jackson (1953) further subdivided partial skin loss burns into superficial partial skin loss (sup. p.s.1.) in which healing took place rapidly from hair follicles or epidermal remnants, and deep partial skin loss (deep p.s.1.) in which healing occurred slowly from epithelial islets derived from sweat glands or the bases of hair follicles in the subdermal fat domes. He describes the naked-eye appearances of sweat-duct healing.
COMMENT
Without doubt, a fairly accurate estimate can be made of the relative depths of an exposed burn, by observation of the varying superficial appearances over it. The superficial appearances of burns are in a perpetual state of change from the time that the burn is first inflicted until about the fifth day. Therefore a single inspection of the burnt surface is often unlikely to give an accurate clue to the depth of burning when it is carried out within a few hours of the injury. Repeated inspection and recording of superficial appearances is much more rewarding diagnostically. Terminology provides another source of error. It is suggested that the term " e r y t h e m a " be restricted to a red burn which blanches on pressure. " Stasis " should be used to describe red burns which do not blanch. The term stasis under these circumstances would include those appearances which are due to both stagnation and extravasation of blood. Burns which blanch on pressure eighteen hours after infliction are almost certain to be superficial partial skin loss injuries. Burns in which " stasis " is present immediately or within an hour after burning are almost certain to require grafting. The aim in modern treatment, once the shock phase of burns is overcome, is to achieve epithelial cover of the burnt surface as quickly as possible by natural means or by skin grafting. Therefore, most surgeons, while not actually committing themselves to paper, use the simple device of classifying burns as superficial or deep--the terminology used by Jean de Vigo in I483 !
242
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
REFERENCES BOYER, J., and GINNARD, L. (1885). " Etudes et Recherches Expdrimentales sur les Brfilures." Paris. DE CHAULIAC, GUY (1363). " On Wounds and Fractures." Translated and published by W. A. Brennan, Chicago, 1923 . CLOWES, G. H. A., jun., LUND, C. C., and LEVENSON, S. M. (1943). Ann. Surg., ziS, 761. CLOWES, W. (1591). " A Prooved Practise for all Young Chirurgians concerning Burnings with Gun-powder and Wounds made with Gunshot . . . " London : Wydow Broome. COCKSHOT, W. (1956). Surg. Gynec. Obstet., xo2, 116. CONVERSE, J. M., and ROBB-SMITH, A. H. T. (1944). Ann. Surg., I2O, 873. DUPUYTREN, BARON (1832). " Lemons Orales de Clinique Chirurgicale," vol. I. Paris. FABRICIUS, G. (161o). De Combustionibus. In " Uffenbach's Thesaurus Chirurgiae~" p. 1144. Frankfurt. HEISTER, L. (1743). " Of Burns and Scalds : A General System of Surgery," p. 22o. London. JACKSON, D. M. (1953). Brit..7. Surg., 4 o, 588. LOWE, PETER (I597). " The Whole Course of Chirurgie." London. RICHTER, A. G. (1799). "Anfangsgrtinde der Wundarzneykunst," vol. I, p. II~. G6ttingen. RUST, J. N. (1835). Aufsfitze und Abhandlungen aus dem Gebeite der Medizin. In " Schrnidt's Jahrbiicher," vol. 5, P. 337. SHEDD, D. P. (1958). Surgery, 43, IO24. SONNENBURG,E., and TSCHMARXE,P. (1915). Neue dtsch. Chit., I7, I. VAN SWlETEN, G. (1745). " The Commentaries upon the Aphorisms of Dr Herman Boerhaave (late Professor of Physics, University of Leyden)," vol. 4. London. DE VIGO, JEAN (1483). " The Whole Works of that famous Chirurgeon master John Vigo ; Newly corrected by menne skilfull in that Arte." Completed and published by Thomas Gale~ M.Ch., London, 1582. WISEMAN, R. (1719). Treatise VI : " A n Appendix to the Treatise of Gunshot Wounds." Eight Chirurgical Treatises. London.
Submitted for publication, July i96z.