The Treatment of Major and Minor Burns

The Treatment of Major and Minor Burns

THE TREATMENT OF MAJOR AND MINOR BURNS R. H. ALDRICH, M.D. DURING the past few months there has been a tremendous increase of interest in the treatmen...

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THE TREATMENT OF MAJOR AND MINOR BURNS R. H. ALDRICH, M.D. DURING the past few months there has been a tremendous increase of interest in the treatment of burns. This is reflected in the medical literature and in the many papers read before various medical societies. The impetus of this interest is undoubtedly the war. It is anticipated that there will be thousands of casualties suffering from burns in the armed services, and it is feared that sabotage and bombing may produce an increase in the number of burns on the home front. The war industries are now contributing to the burned population. Most of the papers recently published unfortunately are based on the same erroneous principles seen in those published in the past. Methods of treatment are advocated with a seeming lack of realization that these self-same measures have been tried and discarded in the past. The history of the treatment of burns has been forgotten or ignored by too many authors. Another common error is the reporting of a small series of cases. It is impossible to obtain accurate data or to evaluate a form of treatment from the report of one case or a short series of cases. The final and perhaps the most glaring error is the reporting of a series of cases treated by one method without dividing the burns into major and minor lesions. Even a large series of burns treated by one method or another results in nothing of importance to the medical profession in the advancement of knowledge unless this distinction is made. A small burn, that is, a burn of less than one fifth of the body area, is as far removed from a burn of 65 per cent of the body area as is tonsillitis from lobar pneumonia. No clinician attempts to report a series of respiratory infections treated by anyone method. Yet many authors report a series of 100 or more bums treated by the same method with no distinction being made as to the severity and extent of the burn. It is obvious that the problems presented by severe burns arc 1229

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not solved by the same methods that are applied to minor burns. No importance can be attached to tables and charts that are padded with mortality figures on small burns from which the patients would not have died if they had received no treatment whatsoever. Even in the treatment of the shock seen in bumed patients, it is self-evident that if the patient needs 1 unit of plasma his condition cannot be compared to the patient who requires 20 units. In the present discussion an effort will be made to divide the consideration of burns into two phases, one dealing with major burns and the other with minor burns. Of necessity more attention will be given to the care of the severely burned patient, since it is in this group that the extreme mortality exists. From papers published in the last two years, it is still obvious that burns involving more than one third of the body area are too often fatal. It is possible to salvage a large proportion of the severely burned if all the problems presented by the patients are solved as they arise. Such treatment requires a flexibility in technic. Each phase of the burn must be understood and combated with the proper form of treatment. The organism as a whole must receive due consideration. Frequently the humed surface is not the most important consideration and must be relegated to a secondary place in order to allow for better treatment of the general condition of the patient. MINOR BURNS

Empirically, a minor burn is one in which less than one fifth of the body area is involved. If there are no complications such as inhalation of superheated air, or if it is not superimposed on a disease, a minor bum presents certain definite problems that are easily solved and should not result in mortality or morbidity. Shock

The most important consideration in minor bums is the determination of shock. A painful second degree minor burn can and does frequently produce a mild state of shock characterized by the usual syndrome of elevation of pulse, fall of l)lood pressure, and diminution of cardiac output. The degree of hemoconcentration is scarcely ever alarming. The initial hematocrit reading is rarely above 50 and if the shock is properly com-

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bated with plasma, serum, whole blood or human albumen, the reading falls rapidly. The shock phase should not be ignored as it may develop into a secondary or delayed phase. The method of Harkins for determining the amount of plasma to use is quite efficient. A hematocrit estimation is made and 100 cc. of plasma are given intravenously for every 1 point rise in the hematocrit reading above the normal of 45. Pain is more frequently seen in minor bums than in the major ones. It is necessary to obliterate it in order to combat shock successfully. Intravenous injection of morphine brings a feeling of well-being to the patient within a very few seconds. Treatment of the Burned Surfaces

Once the shock phase is over the next consideration concerns the burned surfaces. While a bum of one fifth or less of the body area is considered minor, nevertheless such areas afford a portal of entry for infection and the necrotic surface is a good culture medium for the development of organisms. It is generally agreed at the present time that the phase of toxemia seen in bums after the third day is usually the result of a streptococcal infection. The type of treatment indicated in this phase is one that keeps the burned surfaces relatively sterile. It is quite obvious that bland ointments such as vaseline and boric acid are not of sufficient strength to combat local infection. If these are used it is almost always necessary to resort to chemotherapy. As a matter of fact, ointments are merely an adjunctive form of therapy in such cases, chemotherapy by mouth being the primary form of treatment. The local use of the sulfonamides on burned surfaces has been advocated by Pickrell and many others. Their effectiveness is probably due to the absorption of the sulfonamides into the circulation and not to their action on the burned surface. Bradford Cannon and his co-workers at the Massachusetts General Hospital, in a review of the Cocoanut Grove disaster, showed that when a blood level of sulfadiazine given by mouth is built up, the edema fluid under the blebs contains approximately 50 per cent of the blood concentration of the drug. Chemotherapy is definitely indicated as definitive treatment whenever infection appears. It has been shbwn repeatedly in the medical literature in the last two years, however, that the

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sulfonamides are not without grave toxic properties. The morbidity and mortality resulting from their use would make it appear that they should not be used prophylactic ally in every case of suspected infection. In minor burns it is much safer to resort to a nontoxic antiseptic agent for local therapeusis in an effort to prevent invasion of the body by the streptococci. The aniline dyes have for the past fourteen years been employed extensively in the local treatment of burns, with no report of toxic manifestations. The dyes are escharotic and form a flexible, soluble eschar over the burned areas. Such an eschar stops pain by covering the burned nerve endings and acts as a scaffolding for the growth of new epithelium. The contamination on the burned surface is adequately combated by the bactericidal powers of the dyes, and plasma loss from the burned surface is prevented. If any infection does develop under the crust, it is immediately betrayed because of the solubility of the dye eschar. That portion of the eschar immediately over the infection becomes soft and moist and no longer is adherent to the underlying structures. It can be trimmed away with scissors to allow for the removal of the products of infection with a dry sterile sponge, after which the dye is reapplied. In minor burns that do not involve an orifice of the body and that can be kept exposed to air, complete healing frequently occurs under the crust produced by the aniline dyes, with no infection. Orificial burns invariably become infected at one time or another during their healing. This infection can be kept at such a minimum, however, that by constant supervision of the crust, prompt removal of soft areas, and respraying there is little, if any, response noted on the temperature chart. The use of tannic acid on all burns has in general been dropped by physicians who have had adequate experience with it. The British, after one year of war experience, became so alarmed at the many complications arising from the use of tannic acid that they officially forbade it in burns of the hands and face, encircling burns of an extremity, burns of the genitalia and deep burns of other parts of the body. It was noted that when the tannic-acid-silver nitrate technic was used, the majority of second degree burns were converted into third degree ones, and that practically all third degree burns were apparently deepened. It was also observed that the rapid formation

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of an eschar following the use of this preparation constricted the circulation in encircling bums, causing gangrene of the parts beyond the eschar. The Air Ministry reported a large number of cases in which the application of tannic acid and silver nitrate caused a sloughing of the eyelids and lips in burns of the face in R.A.F. pilots. In June, 1942, the Journal of the American Medical Association editorially reviewed the work of Wells and others and cautioned against the possibility of tannic acid causing central necrosis of the liver when applied to burned areas. These findings by the British and Americans would indicate that tannic acid has no part in the armamentarium of the surgeon in combating burns. Unfortunately, the reports on tannic acid have been considered by a number of surgeons to be criticisms of all forms of eschar treatment. None of the above complications accompany the eschar developed by the aniline dyes. The triple dye crust does not lose its elasticity for at least twenty-four h«;>urs after it is formed and the author, in reviewing the case histories in slightly over 1000 burns, has observed no constriction of circulation or deepening of a bum that could be traced to the triple dye crust. MAJOR BU RNS

A major burn empirically is one that involves over one fifth of the body area. Inasmuch as the extent of the burn has a definite bearing on the mortality and the choice of treatment, it is considered advisable at this time to discuss the treatment of the more severely burned patient. The problems presented by a patient with a burn of 50 or 60 per cent of the body surface are common to all major burns, and if they can be solved successfully, the care of the large bum becomes extremely successful. In a major burn there are three main phases. They are (1) the period of shock, (2) the period of toxemia and (3) the period of convalescence under which can be included plastic surgery and general rehabilitation. Shock

. The type of shock seen in a burn does not differ from that seen in most surgical conditions. It has been shown by Cannon, Blalock, Scudder and Moon that the etiology of shock causes little difference in the manifestation of the well recognized syn-

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drome. Shock defies definition. The shock syndrome may be described as a depletion of the vital functions of the body associated with a drop in blood pressure, a lowered cardiac output, and a concentration of the blood due to a change in capillary permeability. The various theories regarding the mechanism of shock need not be gone into fully here. It is the general consensus that the toxic theory of shock is no longer tenable. Hemoconcentration due to a shifting in the water balance of the body with loss of plasma through an altered capillary wall is accepted by most investigators as being the best explanation of the observed phenomena. Perhaps future work will add to our understanding on this point. The standardization of the treatment is well enough established to allow for adequate care of the patient. It is not necessary to argue the points of differentiation between primary and secondary shock and the poorly understood mechanism by which it is produced. When a severe burn occurs, the patient immediately exhibits symptoms which can be called primary or secondary shock depending on the concept of the clinician. There is a rapid drop in blood pressure, both in the systolic and diastolic elements. The pulse rate increases as the heart seeks to compensate for the lowered cardiac output. The patient exhibits the so-called hippocratic facies. There is a lowering of the internal temperature of the body associated with profuse perspiration. There may be extreme restlessness or a comatose condition depending upon the amount of pain produced by the shock and the make-up of the patient. The four fundamentals in the treatment of shock are (1) rest, (2) the application of local heat, (3) control of pain and (4) the administration of intravenous fluids .. These factors are so well understood and have been written about so many times that it is unnecessary to review them in this paper. The important factor in the treatment of the severely burned is the determination of the amount of shock present in order to provide the amount of treatment necessary. The degree of shock accompanying any large burn can be evaluated by a number of methods. These include blood pressure determinations, hematocrit readings, hemoglobin studies, viscosity tests on the blood, and a determination of the volume

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flow of the blood. Anyone, or all, give a good indication of the processes going on in the body and allow the surgeon to determine the routine of the treatment. It should be stressed that the . syndrome of shock constitutes an extreme emergency. The processes associated with shock are reversible only to a certain point. If the patient is allowed to remain in shock for too long a time, irreparable damage occurs which results in death. The hematocrit determination gives a fairly accurate basis on which to begin treatment and is: relatively simple to carry out. It must be assumed that before the patient was burned he had a normal hematocrit reading. As soon as the plasma begins to shift from the circulating blood stream into the injured areas and into interstitial spaces as edema fluid, the hematocrit reading rises. This, of course, indicates a concentration of the blood. The method of Harkins for determining the amount of plasma necessary to combat the increased hematocrit is simple and effective. Harkins advocates giving 100 cc. of plasma intravenously for every. 1 point rise in the hematocrit above the normal of 45. This amount of plasma should be given within twelve hours, after which time another determination is made and further plasma given on the same basis if there is still a deviation from the normal. An increase in the hemoglobin of the blood indicates hemoconcentration in exactly the same way as the hematocrit reading. Plasma can be given until the hemoglobin returns to the normal range. If none of the above tests are immediately available, it is possible to obtain a rough estimate of the general condition of the patient by merely pricking the skin of a finger. If hemoconcentration is present to any marked degree associated with the other physical signs of shock, there is no blood loss from the puncture wound even when the finger is compressed. The treatment of shock is the only consideration of prime importance immediately after the inception of a severe burn. The local treatment of the burned area is of secondary importance and indeed, in many instances, is contraindicated. It is cElnservative to state that, where there are no other complications, death occurring within the first seventy-two hours in a burn of under 75 per cent of the body surface is due to shock and need not happen if adequate treatment is given, except in a

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very small percentage of patients. If the treatment of shock is sacrificed in favor of local treatment of the burn, or if its importance is ignored, the mortality in burned patients will never reach the so-called irreducible minimum. Local Treatment of the Burn

Mechanism Producing the Phase of Toxemia or Infection.There is still a great deal of controversy regarding the best local burn therapy. The fact that such controversy exists indicates lack of understanding of the mechanism producing the phase of toxemia or infection. The theory of toxic absorption was first completely disproved by Underhill, and later by most investigators working on shock. Robertson and Boyd stated that there are toxic· primary and secondary proteoses formed in the site of the burn, being produced by the action of heat on the proteins of the skin. These substances were assumed to be absorbed into the body and were blamed for the phase of toxemia. It is now clearly understood that there is no absorption from the burned area into the body during the shock phase. Edema, even with plasma therapy, does not begin to subside for at least seventytwo hours after the shift occurs. When the shock phase is over there is no evidence to indicate that there is any attempt on the part of the body to reabsorb any part of the burned tissues that are eventually destined to become the slough. The mechanism of the body during this so-called toxic stage is aimed at preventing the slough from being absorbed. There is an infiltration of round cells beneath the burned tissues to form the pyogenic membrane. The blood supply in the burned areas and directly beneath is obliterated by coagulation of blood and lymph stasis. No tissue capable of absorption is produced until after the slough begins to separate and granulation tissue builds up. By this time the necrotic tissue has separated and no part of it can be considered a factor in producing the so-called toxic syndrome. The time element required for granulation tissue to build up further excludes the absorption of a toxin as the cause of the symptoms that appear in most cases of large burns after seventy-two hours. The work of Firor, Aldrich and Cruickshank explains the toxic phase on the basis of streptococcal infection. They showed by bacteriological studies of burned surfaces that, after seventy-

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two hours, the streptococcus outgrows all other organisms. They brought out the concept that a burned surface is an open surgical lesion infected by the streptococcus. There is a constant invasion of the body by the streptococci producing the toxic syndrome. Additional investigation has borne out this theory. When blood cultures are made repeatedly on patients with a septic type fever, it is possible to demonstrate that a transient bacteremia occurs. The culture reports indicate that the same strain of streptococcus that is on the surface is recovered from the blood stream. In fatal burns, cultures of the heart blood and lung reveal again that the strain of streptococcus in the body and on the surface are identical. . If the infectious theory is the true explanation of the second phase seen in the severely burned, certain deductions can be made regarding the proper form of local therapy. At the present time there are four modern forms of treatment for the burned surface. They are: tannic acid, the pressure bandage of Koch, the sulfonamides and the aniline dyes. Tarmic Acid.-Tannic acid has been dropped as a method of choice by most experienced surgeons. In recent months a number of papers have appeared in the literature advocating the use of tannic acid. From the contents of the papers, and the number of cases reported, it is obvious that the authors are new in the field of burn therapy. Their experience has not been extensive enough to allow them to see the complications that have caused other surgeons to discard this form of treatment. The Pressure Dressing of Koch.-The pressure dressing of Koch was originated in an effort to reduce the plasma loss. The tli:chnic for this type of treatment is quite simple. The burned areas are covered with strips of vaseline gauze. There mayor may not have been a preliminary scrub-up. Sterile mechanic's waste is thickly padded over the vaseline strips. An elastic type of bandage is then used to gain compression. The dressings are changed every five to seven days. The theory that such a dressing prevents plasma loss is difficult to uphold. The osmotic pressure acting to allow the plasma to shift is too great to be combated by any pressure other than one great enough to constrict circulation. The most that the pressure dressing can achieve is to cause the edema fluid to move to an unconfined part of the body. It is difficult for the

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advocates of this theory to explain how their dressings can be effective on burns of the abdomen and trunk. Obviously it is not possible to restrict respiratory movements, and where there is definite motion there is bound to be edema fluid. The pressure dressing does not combat local infection. It is necessary to depend upon chemotherapy by mouth to keep down infection under the vaseline strips. The pressure dressing was used at the Massachusetts General Hospital after the Cocoanut Grove disaster. The Burn Committee of that hospital have issued written reports and have given a great many talks on their results. They feel that by chemotherapy they have been able to prevent infection of the burned surfaces. Their statements are somewhat contradicted by the fact that their patients in most instances experienced a marked hyperpyrexia and that when the dressings were changed there was an unmistakable odor. While it is difficult to evaluate a treatment from mortality figures, it is interesting to note that out of all of the victims from the Cocoanut Grove disaster treated at the Massachusetts General Hospital, not a single patient with burns of 40 per cent or more of the body area survived. , Sulfonamides.-The sulfonamides have been used locally on burns for the past three years. Various drugs in this group have been used singly and in combination, and in the form of solutions, ointments, greaseless creams and powders. The results as reported by various investigators have been variable. No one has reported a large series of severely burned patients treated by this method. Pickrell initially reported 115 cases, but in his series there was only one severe burn. The experience of the British in their war burns has not demonstrated the value of the sulfonamides locally on major areas. It has been well established that locally the sulfonamides are of little value in the presence of frank pus. It is extremely dangerous to apply any of the sulfonamides to severe burns because of the amount of absorption that takes place and the possibility of too high a blood level being reached. When burns are treated by Pickrell's solution, it is necessary to spray the areas every hour for as long as fortyeight hours. These repeated sprayings have produced high enough levels of suIfadiazine in the blood stream to cause an enormous amount of crystallization to take place in the renal

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tubules. Pickrell reported one death due to this mechanism and the author has collected reports from the literature of sixteen other deaths due to it. At the present time it would be conservative to state that a great deal more investigational work must be done on the use of the sulfonamides locally on patients with severe burns before their value or toxic properties can be sufficiently proved. As far as can be determined by a search of the literature, no author has reported the survival of a patient with a second or third degree burn of over 50 per cent of the body when the sulfonamides were used locally. Aniline Dyes.-The aniline dyes have been used on all types of burns for the past fourteen years. A sufficient number of cases have been reported to indicate that the dyes can be used safely on burns of any size. The technic of using the triple dyes has been adequately described by the author and others in previous papers and need not be gone into now. At the Boston City Hospital the majority of the Cocoanut Grove victims were treated initially with the triple dyes. After two or three days, as reported by Clowes and Lund, a peculiar modification of the dye treatment was used. This consisted of placing boric strips over the eschar. The rationale for this modification is rather obscure and as far as can be determined from the literature, has not been reported by any other author. The Boston City Hospital had a higher percentage of survival of the severely burned than any other hospital treating the victims of this disaster. At the present time, five and a half months after the Cocoanut Grove Fire, one victim with a burn of approximately sixty-seven per cent of the body area is still surviving and apparently will recover in spite of such complications as the complete exposure of the left tibia and femur, the anterior-superior spines, and a few of the ribs. This victim received the unmodified triple dye treatment as originally described by Aldrich. The rationale for the triple dye treatment lies in its ability to combat infection. Churchman in 1912 showed gentian violet to be a powerful nontoxic antiseptic against gram-positive bacteria. This result was corroborated by the author in 1925. Gentian violet was first used in Johns Hopkins Hospital in 1928. In 1934 the treatment was modified by combining a highly purified form of gentian violet, known as crystal violet, with bril-

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liant green and neutral acriflavine. This combination of dyes has a synergistic action developing antiseptically a high specificity against both gram-positive and gram-negative bacteria. The eschar developed by the triple dyes is flexible and soluble. It betrays any underlying infection by becoming soft and moist and can be removed to allow for a reapplication of the mixture. Even in large burns infection can be kept minimized by this process of removal and reapplication whenever it is necessary. Under this type of treatment severe burns undergo a greatly reduced toxic phase, and in those burns that can be kept free from infection there is no toxemia. Early Complications in the Severely Burned

Early complications seen in the severely burned are lung involvement, anuria and hemoglobinuria. Lung Involvement.-In extensive flame burns, especially those produced in an enclosed room, involvement of the lung is quite common. This is due to inhalation of flame and smoke or to inhalation of superheated air. For many years the New York Fire Department has conducted an educational program aimed at getting people to refrain from opening doors without feeling them when they attempt to locate a fire. They have shown, for example, that in an apartment house fire the temperature in the corridors well removed from the flames can be as high as from 200 0 to 300 0 F. The inhalation of such superheated air can produce injuries ranging from immediate death to late lung and blood changes. If the air is hot enough, the lining of the trachea and bronchi can be injured to such an extent as to reduce tidal air to zero, bringing about rapid suffocation and death. Apparently, a large number of the victims of the Cocoanut Grove disaster suffered this type of complication. If the inhalation does not produce immediate death, after several hours edema of the lungs sets in, associated with the formation of a necrotizing membrane in the trachea and bronchi. The patient's lungs begin to fill up rapidly and cyanosis appears. If the trunk of the pa·· tient is lowered, there is a dicharge of a thin bloody fluid in profuse amounts from the mouth and nose. When this fluid has drained out the patient experiences relief for a short period of time, but inevitably the lungs fill up again and the patient dies after twelve to eighteen hours.

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Hemoglobinuria.-With the previously described changes in the lungs produced by the action of superheated air, there is at times an associated hemoglobinuria. When this complication is seen, it usually indicates a fatal tennination, although a small percentage of patients can be saved. A theory advocated by Wintrobe concerning the mechanism of production of hemoglobinuria in burns is plausible. When the red blood cells enter the alveoli and come in contact with superheated air, their cell walls are injured and there is an increase in the erythrocytic fragility. Within a few hours the red cells begin to break down and the plasma becomes stained pink. Hemoglobin presently appears in the urine. The author has observed hemoglobinuria in severe burns caused by hot water and steam that did not involve the lungs. The mechanism in these cases was undoubtedly the same as in burns of the lungs. The blood vessels beneath the burned areas became superheated and transInitted enough heat to a percentage of the red cells to cause a change in the fragility with resulting hemolysis. In these cases the plasma was a paler pink than the color noted in the plasma of patients who had lung involvement. Anuria.-Anuria is frequently seen in severely burned patients. It formerly was attributed to kidney damage. It is impossible to state at what period anuria sets in, the amount of urine in the bladder giving no indication as to when the kidneys cease to function. All cases of anuria following burns are observed when hemoconcentration has developed. The hemoconcentration is undoubtedly the explanation of the lowering of the function of the kidney. There is a relative increase in the red blood count and a definite increase in the viscosity of the blood. These two factors produce a greatly reduced blood flow through the malpighian bodies. Experimentally it can be demonstrated in the capillaries of the mesentery of animals that when hemoconcentration takes place following shock, there is little, if any, forward progress of the red cells. Anuria can be aborted by immediate shock treatment to prevent hemoconcentration. Lflte Complications in the Severely Burned

The two most important late complications in severely burned patients, aside from infection, are nutritional disturbances and a disturbance in the metabolism of the proteins. A

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third complication is the progressive secondary anemia seen in all cases of extensive burns. Nutritional Disturbances.-A severely burned patient because of discomfort, inability to move, and toxicity usually has no desire for food and, in most cases, is uncooperative. He becomes a difficult problem because the ingestion of high caloric, high protein and high vitamin foods or food elements is vitally needed for the repair of his injuries. In patients with severe burns there is a marked anabolism of protein with a tremendous rise of urinary nitrogen and an increase of nitrogenous elements in the stool. In many burns of over 50 per cent of the body area, the urinary nitrogen rises to 40 and 50 gm. every twenty-four hours. This amount of nitrogen requires the catabolism of 300 gm. of protein a day. If such an amount of protein is not supplied in the diet, the patient will utilize his own proteins to supply his needs and as a result will suffer profound nitrogen deficiency. Associated with this hypoproteinemia there is a change in the osmotic pressure in the capillaries and extensive edema in all parts of the body. The total protein of the blood frequently drops to as low as 2 mg. per 100 cc. It has been found that the intravenous administration of plasma alone is not sufficient to bring the total blood protein back to normal. Even human albumin alone will not successfully combat this condition, although it is much more efficacious than plasma. It is necessary to have the patient take by mouth daily a diet containing 300 to 500 gm. of protein with a value of 3000 to 4000 calories. If this cannot be done by feeding the patient an ordinary meal, a concentrate can be made in liquid form and given to him by tube feeding. If this is not done, the patient with a hypoproteinemia and a nitrogen debt invariably dies. From recent vitamin studies it is evident that, in a patient with an infection to combat and tissues to be restored, a high intake of all of the vitamins is essential. The exact requirements for vitamins in the treatment of the severely burned have not yet been determined. It is necessary, therefore, to overdose the patient in order to make certain that he will receive as many units of all of the vitamins as he needs. Anemia.-There is a constant blood destruction by the invading organisms in most large burns. It has been established by Castle that for the formation of the necessary number of red blood corpuscles to replace those lost by infection and by the

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natural processes, there must be an adequate intake of the food elements of proteins, fats, carbohydrates, vitamins, mineral salts and water plus iron and the erythrocyte-maturing factor. If there is a nutritional disturbance or an insufficient intake of these elements, a steadily progressive anemia results. In practically all large burns new red blood cells must be given by transfusions at least once a week and frequently every second or third day. If the hemoglobin is allowed to fall below 65 per cent, there is no appreciable tissue building. The patient with this low hemoglobin concentration is also much more prone to infection and usually does not survive unless the anemia is adequately combated. Intercurrent Infections.-In many hospitals burns are considered as infected cases and have not been wanted in a general surgical ward for fear that the infection would spread to other patients. A patient with burns should be isolated, but for the reverse reason. He is a debilitated person with an extremely large portal of entry for infection. Every effort should be made to prevent infection reaching him from the general ward population. Ideally, he should be isolated in a private room and only the necessary visitors and attendants should be admitted. Every person entering the room should wear a clean gown and mask. If a visitor or an attendant has an upper respiratory infection, he should be excluded until there is no chance of a spread to the patient. Every effort should be made to maintain the patient in the best possible health to prevent the occurrence of respiratory infections. A team composed of the surgeon in charge of the case and an internist makes for better care of the patient in combating intercurrent diseases and infections. Skin Grafting.-The extreme burn presents one problem that has not been generally considered. While it is known that a Thiersch graft gives the best cosmetic result on most areas, it is frequently impossible to obtain enough skin from the patient himself to cover the large surface that is burned. Also, because the mortality is influenced directly by the size of the burn, it is desirable to carry out skin grafting as early as possible once it is. definitely established that the epithelium will not spread from the bases of the hair follicles and sweat glands. Early grafting, when there is still infection, occludes the possibility of using the Thiersch technic. In the author's experience a very thin pin-point graft has been

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the most satisfactory type. From a very small donor site it is possible to obtain enough grafts to cover a rather wide recipient area. The grafts should not be cut deeper than the uppermost limits of the capillary bed. A higher percentage of take will be obtained if they are kept as small as Ys inch in diameter. It is not necessary to take the grafts in rows leaving skin between. They can be cut so close together that the donor site resembles the picture presented when a Thiersch graft is cut. Within two weeks the same donor site can be used again. The type of postoperative care given the recipient site has a direct bearing on the percentage of living takes obtained. The author places a single layer of sterile gauze over the grafts after they have been put in place. This is done by opening a sterile sponge until it is only one layer thick. Flexible collodion or liquid adhesive can be used to seal the gauze around the edges. The recipient site is exposed to air for eight hours. After this period sterile gauze sponges, are generally placed on top of the original gauze and are sprayed with sterile saline every hour. Every four hours the sponges are removed with care and new ones applied. This process continues for five days after which time the original single layer of gauze is removed. If the grafts are to live, they have taken by this time. If any are still loose they are to be considered dead .. This technic usually gives about a 95 per cent take, even in the presence of some infection. It is necessary to maintain the hemoglobin at a higher level than 65 per cent in order to insure success. After the fifth day the grafts can be treated by any technic the surgeon desires. Wet dressings are usually uncomfortable, since they dampen the bed and chill the patient. A cod liver oil ointment with a wax base provides a soothing and stimulating dressing. If this is used it should be changed every twelve hours. The grafts usually spread rapidly and reduce the open surface area. BIBLIOGRAPHY

Aldrich, R. H.: Superficial Burns. In Mason, R. L.: Preoperative and Postoperative Treatment. Philadelphia, W. B. Saunders Co., 1941. Also chapters on Burns and Shock in 1943 edition, in press. Aldrich, R. H.: A Critical Survey of the Treatment of Burns. J. Maine Med. A., 33(2):21-30 (Feb.) 1942. Aldrich, R. H.: Burns in Children, Abstract of Discussion. J.A.M.A., 118(5): 349 (Jan. 31) 1942.

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