FIRST-AID TREATMENT OF BURNS AND SCALDS

BY

LEONARD COLEBROOK, THOMAS GIBSON, AND J. P. TODD

From the Medical Research Council Burns Unit, The Royal Infirmary, Glasgow

In writing about the management of burns it isimportant to distinguish clearly between:

(a) Treatment applied as a purely temporarymeasure at the scene of the accident, beforethe patient is despatched to a hospital ordoctor. This is strictly first aid.

(b) The formal treatment, carried out by a doctoror nurse, whether in the horiie, the surgeryor the hospital, who has adequatefacilities at his command. This we havetermed, at the suggestion of Sir AlmrothWright, the plenary treatment, to conveythe idea of completeness.

(c) Subsequent dressings, skin grafting pro-cedures, etc.

The present paper is concerned only with firstaid-and almost entirely with the local treatment ofthe burn. Civilian burns have been chiefly in mind,but the principles underlying treatment are the samefor burns sustained on active service.

There is no agreed policy with regard to theinitial treatment of burns. Owing to the urge todo something, however ill-advised, 75 per cent. ofcivilian patients arrive at hospital with some kindof application to the burned area-olive oil, flour,coagulant jellies, cold tea, sodium bicarbonate, an'ointment,' or flavine, etc.-often covered with adirty, or at least a non-sterile, piece of cloth.

Frequently pain has not been relieved by theseapplications-sometimes it has been increased;and the difficulty of removal of the semi-coagulatedjelly, the oil or the caked flour, may well aggravatethe original trauma suffered by the burned tissues,thereby favouring the development of shock.

First-aid remedies of this kind, especially ifapplied, as they usually are, without aseptic pre-cautions, may well do much more harm than good.

In view of the great importance of burns in themechanized warfare of to-day, and their contribu-tion to wastage in industry, we have attempted toformulate a simple first-aid procedure which wouldbe generally applicable, and have a satisfactoryraison d'c6tre.Such an ideal first-aid procedure should:

(a) Relieve pain promptly and, by so doing,cut off sensory stimuli which probablyplay some part in inducing shock.

(b) Prevent the arrival of pathogenic organisms99

-in particular of haemolytic strepto-coccus-on the burned surface; or, ifthis has already happened, destroy it orprevent its multiplication.

(c) Do no further damage to the already in-jured but viable skin tissues, nor interferewith the natural anti-bacterial defence byleucocytes.

(d) Be easily removed by gentle washing with awatery solution during the subsequentclean-up in hospital or the surgery.

(a) Relief of PainThis was studied in two ways

(1) By direct observation on small experimentalburns on the human subject.

(2) By the application of creams containinganalgesic agents to a series of accidentalburns in factories and in the Burns Wardof the Royal Infirmary, Glasgow.

The experimental human burns were caused by aflat-bottomed copper tube through which water attemperatures of 550 to 60° C. was circulating (Leach,Peters and Rossiter, 1943). Light pressure withthis tube on the forearm for 45-50 seconds gave afairly uniform, manageable, second-degree burn,which was more painful than burns caused byhigher temperatures for a shorter period.

Observations on some twenty-four of these stan-dard low-temperature burns showed:

(i) That exposure to air caused pain and hot airincreased it. The burned area is partiallyanaesthetic (prick test).

(ii) That cold water or any cold watery creamgave instantaneous relief (cooling effect),but this was usually short-lived and wasfollowed by a variable amount of burningor throbbing which lasted for an hour ormore.

(iii) The application of local analgesics in a creamcomposed of-

Cetyl trimethyl ammoniumbromide (' Cetavlon ')

Cetyl alcohol ..Linseed oil ..Water to ..

1 per cent.5 ,

25 ,,100 ,,

sometimes afforded more relief than thecream alone but the effect was not constant

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BRITISH JOURNAL OF INDUSTRIAL MEDICINE

in different individuals. The local anal-gesics tested were:

Orthocaine B.P. (' Orthoform') 2 per cent.Benzocaine .. .. .. 05Percaine .. .. ..I

The effect of these analgesic creams on accidentalburns was similarly difficult to assess. At Messrs.Rolls-Royce, Ltd., the medical officer and hissurgery staff were definitely of the opinion that thecream containing orthocaine was superior tothose with other analgesics, and to the same cream

without any analgesic. He also reported that verysatisfactory healing, with almost no sepsis, resultedwhen this cream was left on the burns as the soletreatment. At another factory, Messrs. G. and J.Weir, Ltd., the medical officer and his assistants didnot get such a clear-cut impression. In the BurnsWard at the Royal Infirmary the relief obtainedfrom application of the orthoform cream was alsosomewhat variable. It was noted that many ofthe burns on arrival at hospital within half an hourto 2 hours did not complain of pain.No toxic effects were observed from the use of

these analgesics but they were not applied to exten-sive burns. We are informed by Lt.-Col. J. BarrettBrown, of the U.S. Army Medical Service, that sucheffects have been reported in America, particularlywith percaine.

(b) Preventing InfectionOne event is especially to be feared in connection

with every fresh burn, namely, infection of thesurface by the haemolytic streptococcus. If thisdoes not occur the great majority of superficialburns heal within 7-20 days; if it does occur thedamage to tissues is usually increased, healing maybe much delayed, and, if the burned area involvesflexures, contractures are likely to result.

In some cases a spreading cellulitis or lymphangitismay develop and constitute a threat to life. Thelate deaths (after the fourth day) are not infrequentlydue to such an invasive infection. Staphylococcalinfection of the fresh burn may also be troublesomeand delay healing, but seldom has such seriousconsequences as those due to streptococci.Under the existing haphazard arrangements for

first aid to burns both these infections are very

common. Table 1 shows the incidence of strepto-coccal contamination of 516 burns on arrival at theGlasgow Royal Infirmary (1942-3). Within thefirst 12 hours after burning only 4 per cent. yieldedhaemolytic streptococci-and the proportion ofpositives was considerably lower for cases examinedwithin 3 hours. After 12 hours the proportion ofinfected cases rises steeply.

TABLE 1

Number of hoursafter injury

0-1212-24

More than 24

Number ofburns

examined37039107

Haemolytic strepto-cocci present

15=4-05 per cent.9=23 145=42 05 ,,

Of all the minor burns treated as out-patients 30 percent. were infected with haemolytic streptococci at theirfirst visit to the hospital.

The primary object of all first aid to burns shouldbe the prevention of these streptococcal infections.It should seek, in the first place, to prevent thearrival of any streptococci on the burned surfaces;and, if they have already arrived there, it shouldseek to destroy them or at least to prevent theirmultiplication.

How to prevent the arrival of Haemolytic Strepto-cocci on the Burned Surfaces

Haemolytic streptococci are rarely found onnormal human skin (see below); and it follows,therefore, that those which infect burns must usuallybe derived from sources other than the patient'sown skin.

Colebrook, Maxted and Morris Johns (1935)isolated haemolytic streptococci (group A) fromonly 7 of a group of 181 factory workers, and thecircumstances suggested that in some of the 7 theorganisms.might have come there from the respira-tory tract. The same authors failed to isolate anygroup A strains from the perineum and thighs of160 parturient women. Hare (1941) in Canadaisolated only one group A strain from the hands of248 students. Colebrook (1930) also showed thatwhen haemolytic streptococci were experimentallydried on the skin of the hands they did not remainviable for more than a few hours.

It is not difficult to visualize the many sourcesfrom which burns may acquire these infecting cocci.Haemolytic streptococci are widely distributed inall human communities of the temperate zones,being associated with, and continually disseminatedfrom, many common infectious processes, e.g. cellu-litis and septic sores, erysipelas, impetigo, whitlows,scarlet fever and tonsillitis, otitis media and chronic' running ears' of childhood, puerperal fever. etc.In addition they are present in the nasopharynx ofmany healthy carriers (5-30 per cent. of thepopulation) who project them into their environ-ment by coughing, sneezing, etc. Less commonlythey proliferate in the nose of nasal carriers, andthese individuals are especially dangerous becauseof the continual seepage on to handkerchiefs, clothes,hands, etc. From all these sources haemolyticstreptococci find their way into the air of publicplaces and private houses; they remain viable forlong periods in dust and are freely disseminated bythe sweeping of floors and the shaking of blanketsand other bedding. (Thomas, 1941; Colebrooket al. 1944.)

Finally, it should be noted that, although haemo-lytic streptococci cannot survive in the acid secretionof normal skin, they multiply very rapidly in theserous exudate of burned surfaces and commonlypersist there for long periods.

Clearly it will not be easy to prevent the freshburn from contamination from so many potentialsources ; and without strict precautions first-aid

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FIRST-AID TREATMENT OF BURNS AND SCALDSprocedures may themselves provide the medium forsuch contamination. There can be little doubt thatin the past they have often done so.

First-aid personnel should wear efficient maskscovering the mouth and nose, or, if these are notavailable, a clean handkerchief will serve. The burnedsurface should be covered as soon as possible witha sterile cloth or at least a recently laundered cleantowel. Blankets are seldom sterilized at the laundryand therefore are very apt to be contaminated withpathogenic organisms, including haemolytic strepto-cocci. They should on no account be allowed totouch the burned surface.The hands of first-aid personnel should be care-

fully washed for at least 2 minutes, and then driedon a clean towel, before any treatment of the burnis undertaken.

If the burn is extensive and cannot be exposedwithout removal of clothes, the patient should besent straight to hospital without any first-aiddressing of the surface.

How to deal with Haemolytic Streptococci whichhave already arrived on the Burned Surface

First aid should include a minimum of inter-ference with the burned surface because the con-ditions will seldom be such as to allow of strictlyaseptic procedure. For this reason the burn shouldnot be washed nor should blisters be snipped.The bactericidal or bacteriostatic agent employed

should be in the form of a water-soluble creamwhich can be easily washed off during the subse-quent plenary treatment, rather than a jelly orcoagulant solution, such as tannic acid, which willbe difficult to remove. Bactericidal dyes, likegentian violet, although they may have advantagesin some special circumstances, e.g. on small ships,are not recommended for general use because theyprevent the medical man who subsequently treatsthe case from forming any opinion as to the depthof the burn. They are also highly toxic to thealready injured skin tissues, and cannot be washedoff during plenary treatment. They cannot berelied upon to sterilize the burned surface withcertainty.Of the anti-bacterial agents available at present

the new synthetic detergent, cetyl trimethyl ammo-nium bromide ('Cetavlon') seems likely to be themost effective for the first-aid treatment of burns.Barnes (1942) showed that, in addition to itscleansing effect on normal skin, it was remarkablyeffective in getting rid of 'resident' organisms-apparently reaching those in the depths of sweatand sebaceous glands and hair follicles more success-fully than the substances previously employed asskin antiseptics. Our own experiments and thoseof Williams et al. (1942) have confirmed this, andalso the fact that Cetavlon has a rapidly lethalaction on haemolytic streptococci. Because of itsfoxic action on leucocytes and tissue culture cells(Barnes, 1942; Jacoby, 1943) it cannot be regardedas the ideal substance to apply to tissues which we

want to regenerate, but in actual practice with burnsthe risk of any toxic effect has proved very slight.Apart from three instances of sensitization-derma-titis (see note below) no irritant effects have beenobserved among the two thousand burns to whichCetavlon has been applied in Glasgow during1942-3; nor has it seemed to delay healing.Cetavlon also has the disadvantage of being a

potent protein precipitant, and thereby forfeitsmuch of its anti-bacterial potency in presence of theserous exudate of burns. As shown in Table 2,however, this anti-bacterial effect is by no meansabolished by serum or blister fluid. Pending thediscovery of an equally potent anti-bacterial sub-stance which is free from these defects Cetavlonappears to be the most suitable one for the first-aid application to burns. By virtue of its powerfuldetergent properties it will remove most of the de-tachable organic material from the burned surfaceand surrounding skin, and thereby greatly facilitatethe destruction of bacteria. It is, moreover, notincompatible with sulphonamides, so that these twoanti-bacterial agents can be combined in a first-aid cream.Such a combination seemed desirable for two

reasons: (1) because the bacteriostatic effect of thesulphonamide would reinforce that of the Cetavlon,and (2) because sulphonamide was likely to bemore effective than Cetavlon in controlling aninfection by haemolytic streptococci which hadalready invaded the tissues, e.g. in burns severalhours old when first seen.

Several such combined creams were prepared fortrial at the Glasgow Royal Infirmary by one of us(J. P. T.). The most satisfactory one ('No. 9Cream') had the following composition:

Cetyl trimetyhl ammonium bromideSulphanilamide..Castor oil ..Beeswax ..Wool fat ..Cetyl alcohol ..Glycerin. . . . .. .

Water . . .. .

I gm... 10 ,,*.. 25. . 1-8 ,,.. 18 ,,

. . 5 ,,

.. 10

.. 45.4 ,

It is prepared as follows: Melt the castor oil,beeswax, wool fat and cetyl alcohol at as low atemperature as possible. Dissolve the Cetavlon inthe water with the aid of heat and mix with the oil,etc., at about 600 C. and stir till set. The sulphanil-amide is then rubbed up with an equal weight ofglycerin, the two together comprising 20 per cent.of the final product. This sulphanilamide-in-glycerin is then incorporated in* the cream and

* Recent batches of No. 9 Cream have contained only 3 per cent. ofsulphanilamide. This reduction was decided upon when it was foundthat a toxic dose of the drug may sometimes be absorbed fromextensive burns dressed with the 10 per cent. cream. (Contrary toour expectations this excessive absorption occurred in patients withdeep, heat-tanned burns rather than in second-degree burns.) Ex-cessive absorption from a 3 per cent. cream would be very unlikely.Even if as much as 300 gm. were used for a single application itwould contain only 9 gm. of sulphanilamide. Only part of thiswould be absorbed, and its absorption would be spread over severalhours; part would seep away into the dressings after solution in theexudate; and some would probably remain undissolved. On theother hand, 3 per cent. of sulphanilamide is probably more thanenough to give the desired prophylactic effect.

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BRITISH JOURNAL OF INDUSTRIAL MEDICINEthoroughly mixed. A Peerless Mixer with bent armat slow speed has given the best results, but it isquite possible to make the preparation by hand,although not quite so well.

(NOTE.-This cream cannot be heated to sterilizeit, but it can be regarded as self-sterilizing for theordinary non-sporing pathogens. Samples experi-mentally contaminated with staphylococcus aureus,B. proteus and Ps. pyocyanea have always beenfound free from viable organisms after 24 hours.It is possible that spores of pathogenic clostridia,including tetanus, might survive in it (this point isbeing investigated), but the risk of such contamina-tion may be regarded as extremely small. Whenthe cream is to be kept for long periods chlorocresol(0-2 per cent.) should be added to it to prevent anygrowth of moulds.)

In vitro Tests with No. 9 Cream and other First-AidRemedies in common use

To find out how much bactericidal or bacterio-static effect was to be expected in the presence of acopious exudate of blister fluid on the surface of aburn, tests were carried out as follows:

1 c.c. volumes of blister fluid (if available), orof serum, were inoculated with staphylococci andhaemolytic streptococci, and then vigorously shakenwith a large loopful (40 mg. approx.) of the creamor other first-aid remedy. Viable counts weremade (with adequate dilution but without chemicalneutralization of the bactericidal agent) before theaddition of the test substance, and again after24 hours incubation with it at 370 C. Typicalresults are shown in Table 2:

It is seen that:(a) In blister fluid alone staphylococcus aureus

and haemolytic streptococcus multipliedfreely. (This is not the case with someof the non-pathogenic 'micrococci' nor-mally resident on the skin.)

(b) In presence of No. 9 Cream and the dye-jellies used these organisms were killed off.

(c) In presence of tannic acid, phenol had notany antiseptic action, while acriflavinealso was largely neutralized, allowingstaphylococcus to grow out, althoughstreptococcus did not.

By this test No. 9 Cream appears at least as satis-factory as the jellies containing bactericidal dyes,and it has the important practical advantage overthese that it can be readily washed off for theplenary treatment, allowing the medical man toestimate the depth of the burn.

It is recognized that these in vitro tests as per-formed do not reflect exactly what would happenon the surface of a fresh burn, because they takeno account of any fixation of the antiseptic agentby the tissue cells of the burned surface. Otherobservations, which will be reported elsewhere,showed that washing over a fresh burn (i.e. notmore than 24 hours old) with Cetavlon solution didusually reduce the bacterial contamination of thesurface from a matter of 'thousands' to nil oralmost nil. We think it may be presumed that asimilar effect will be obtained with No. 9 Cream.

Clinical Trials of First-Aid CreamsFollowing upon these tests in the laboratory

observations were made upon two series of minorburns attending Glasgow Royal Infirmary in orderto determine if possible how far the application ofthe creams was preventing infection by haemolyticstreptococci.

Series I. Two creams were used, viz. No. 9 asdescribed above, and a simpler one, 'CetavlonCream,' containing no sulphanilamide. Its com-position was: cetyl trimethyl ammonium bromide1 gm., cetyl alcohol 5 gm., linseed oil 25 gm., water69 gm.

TABLE 2

Staphylococcus aureus Haemolytic streptococcus

Before After Before Afterincubation incubation incubation incubation

.Experiment 1.Blister fluid alone .. .. .. 80,000 18,000,000 19,000 13,000,000Blister fluid+' Tannafax' (tannic

acid+phenol, 0 5 per cent.) .. 80,000 2,000,000 19,000 600,000Blister fluid+No. 9 Cream .. .. 80,000 0 19,000 0Blister fluid+' Triofax' (gentian,

violet, 1 per cent.+brilliant green,0- 1 per cent. +euflavine) .. .. 80,000 0 19,000 0

Blister fluid+gentian violet jelly(gentian violet, 1 per cent. +mer-thiolate, 0-02 per cent.) .. .. 80,000 0 19,000 0

Experiment 2.*Serutn alone .. .. .. .. 300,000 10,000,000 150,000 15,000,000Serum+tannic acid+ acriflavine, 300,000 2,000,000 150,000 0

0 1 per cent.

* In this experiment No. 9 Cream, 'Triofax' and gentian violet jelly gave the same result as in experiment 1.

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FIRST-AID TREATMENT OF BURNS AND SCALDS

Consecutive cases (not severesion) were treated as follows at tiA moist swab (A) was rubbed cface for subsequent bacteriolBlisters, if present, were not ofdebris removed; nor was an)clean up the burned surface in (

substances previously applied-csemi-coagulated jellies, etc. Awith one of the two creams, cwool and a bandage, the patiennext day at the out-patient busecond swab (B) was takenexamination, and the burn thenplenary treatment *-blister skthe surface gently cleaned withand a sulphanilamide dressing apatients were treated in thiscream and sixty-two with No. 9.The clinical results of these tr

factory-the dressings havingfrom the first in the great majthe burned surfaces either healewhen the patients came back aftThe bacteriological evidence z

infection is shown in Table 3:

TABLE 3

Group 1. Cases in which creamwas applied within 24 hoursof the injury. Total 119

Did not become infected withH.S. (haemolytic strepto-coccus) .

H.S. present in first and secondswabs ..

H.S. present in first swab butdid not persist .

Became infected with H.S. afterapplication of cream

Group la. Cases belonging toGroup 1, but in whichthe second swab was takenmore than 24 hours after in-jury. Total 68

Became infected with H.S. afterapplication of cream

Approximate number in whichH.S. infection was to be ex-pected after 24 hours (seeTable 1) if cream had notbeen applied

Group 2. Cases to which creamwas applied 24 hours or moreafter the injury. Total 25

Did not become infected withH.S. ..

enough for admis-heir first attendance:wver the burned sur-ogical examination.pened nor epithelialy attempt made toorder to remove the:aked flour, vaseline,Jfter being dressed-overed with gauze,

TABLE 3-continuedCetavlonCream

H.S. present in first and secondswabs ..

H.S. present in first swab butdid not persist .

Became infected with H.S. afterapplication of cream

No. 9Cream

2 8**

0 0

2tt 1§10 15

it was told to report The data in Table 3 suggest the following tentativerns clinic. Here a conclusions:for bacteriological (1) That temporary dressing of the burns with

i received its full or cream in the 68 cases of group 1 a did to somezin being removed, extent prevent their becoming infected with haemo-Cetavlon solution lytic streptococci. In view of the figures in Table 1,

pplied. Eighty-two it seems reasonable to suppose that many moreway with Cetavlon than 4 of these 68 cases would have been so infected

after 24 hours if they had been left alone. (It must,ials were very satis- however, be admitted that any sterile dressing wouldbeen comfortable have had some protective effect.)

jority of cases, and (2) That the creams used were not usually success-3d or almost healed ful in getting rid of the haemolytic streptococciter one week. already present on the burned surfaces at the timeas to the control of of the first swab. The failure to get rid of them in

6 cases out of 7 should, however, be viewed in thelight of footnote.t It may well be that we shouldhave had more success if all the cases had been

Cetavlon No. 9 burned only a short time and if the burns had notCream Cream been smeared with 'white ointment,' vaseline,

jellies, etc., before the cream was applied. Thefailure to eliminate haemolytic streptococci fromburns to which our creams were applied late, i.e.

66 42 more than 24 hours after injury, did not surpriseus, because Barnes had previously shown that

2t 4t Cetavlon did not reduce the bacterial count of a0 1 granulating surface, and our own experience with

definitely infected burns had confirmed this many4+ 0 times. Once the streptococci have invaded the

72 47 tissues Cetavlon is probably of little or no use.Series II. In this series of 104 minor burns only

No. 9 cream was used and the procedure wasmodified slightly in the hope that we should get stillbetter control of infection. The various applica-tions made before coming to hospital were removedas far as possible; a swab (A) was then taken forbacteriological examination; blisters were usually

4+- emptied (but blister skin not cut away); the burnedareas were then washed over with Cetavlon solution,and No. 9 cream applied for periods varying from12 to 48 hours. The second swab (B) was then

20 to 30 taken and the usual plenary treatment applied.Seventy-three cases were free from streptococci

when they first came to the hospital (A swab) andnone had acquired them when the B swab was taken20-40 hours later-with two exceptions, for which

6 6 there was a sufficient explanation. One of these

* It should be made clear that the above procedure was adoptedonly to obtain evidence as to its efficacy in preventing infection bystreptococcus. If this object had not been in view the plenary treat-ment would have been carried out at the first visit to hospital.

t Of these 6 cases, 3 had been burned 21 hours or more before thecream was applied, so that invasion of the tissues had probably begun.

t One of these had been covered with lanolin and another withflour, which may have prevented effective contact of the cream.

* * These patients had been burned respectively 27 hours, 2 days(2 cases), 3 days (2 cases), 31 days, 5 days and 7 days.tt One of these burns was covered with ointment, the other had a

heavy coagulant dressing of gentian violet, which probably preventedsatisfactory contact of the cream.

§ This is open to doubt; the first swab gave a confluent growth ofstaphylococcus in which a few haemolytic streptococcal coloniescould easily have escaped detection.

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BRITISH JOURNAL OF INDUSTRIAL MEDICINEwas a boy who did not reappear for 7 days afterthe first-aid treatment was applied; the other, achild which pulled off its dressing before it cameback for the second swab.Of the 31 patients who already had haemolytic

streptococci in the A swab, 8 had lost them beforethe second swab was taken-presumably as a resultof the first-aid treatment. Of the remaining 23patients, who did not lose their streptococci, 20 hadbeen burned more than 24 hours before they cameto hospital and 2 of the others were burned 16 and20 hours respectively before treatment.These results certainly suggest that the cream and

the Cetavlon solution were effective in holding offstreptococcal infection in this series of burns.

Commentary upon these Clinical Trials

1. We do not claim to have proved conclusivelythat the first-aid procedures adopted have pre-vented infection by streptococci, although we thinkthat the findings point to a large measure of successand warrant a more extended trial of the methods.

2. A random series of hospital patients, some ofwhom have been burned many hours or even daysbefore, and have had divers applications, cannotyield clear-cut results. Future comparative trialsof first-aid remedies should be made on fresh burnswhich have had no previous treatment.

3. Medical officers of large industrial organiza-tions, e.g. foundries where many minor burns occur,in collaboration with a bacteriological laboratory,could obtain valuable data by comparison of casestreated with No. 9 or other antiseptic cream, withother cases treated with the same cream withoutthe antiseptic.

Note on Sensitization to CetavlonIn the course of this work we have encountered

three instances of severe vesicular dermatitis ap-parently induced by the application of Cetavlon.In two of these the condition developed after theCetavlon cream had been in contact with the burnedareas for several days (12 days in one case) ; in theremaining case the solution of Cetavlon had beenapplied to the skin on only three occasions and thedermatitis developed 7 days after the third applica-tion. In all three the condition cleared up within2-3 weeks, after becoming more or less generalizedand associated with some degree of toxic disturb-ance. A scratch test with a 1-5 per cent. solutionof Cetavlon gave a definite positive result in allthree cases after the dermatitis had cleared up. Asimilar test with potassium bromide in two of thecases gave a negative result. Potassium bromideby mouth in one case produced a slight eruption.. One of the patients has had two recurrences ofthe dermatitis at intervals of several months-oneof them definitely induced by accidental contactwith Cetavlon.

These three are the only cases of dermatitis wehave met in a total of more than 2000 burns towhich Cetavlon has been applied at the GlasgowRoyal Infirmary. We are inforned by Dr. R. G.

MacFarlane that a 1 per cent. solution has beenused for cleansing the skin of some 2160 blooddonors in the West of England and that no derma-titis has been reported to date.

Conclusions1. The avoidance of infection by haemolytic

streptococcus should dominate first-aid policy forall but very severe burns. In the latter, measuresfor the preservation of life will often have to takeprecedence over local treatment of the burn.

2. For most small burns which are accessible,e.g. of the hand or forearm or head, first aid atthe scene of the accident should usually be limitedto covering with a recently laundered clean towel,or, better, if it is available, with a sterile cloth.(Wherever burns are likely to occur such clothsshould be kept ready, previously sterilized in anoven and stored in a tin.) The burn thus coveredshould be sent at once to the factory surgery, or ahospital, or a private doctor.

In all severe or extensive burns no first aidshould be attempted other than keeping the patientwarm and giving morphia if required. Immediateremoval to hospital is the first consideration.

3. When quite superficial small burns are treatedat home or when, in the case of more severe burns,the plenary treatment cannot be carried out withoutconsiderable delay, it is recommended that the burnedarea, and the skin around, should be freely smearedwith a water-soluble cream containing 1 per cent.of cetyl trimethyl ammonium bromide (' Cetavlon')and 3 per cent. of sulphanilamide. This creamshould be applied with a knife blade or spoon,previously sterilized by dipping for 2 minutes inboiling water. The burn should not be washedbefore the cream is applied nor should blisters besnipped.

This first-aid treatment must be carried out withdue precautions against the transfer of streptococcito the burned surface. Thus, the operator's handsmust be thoroughly washed and dried; and heshould wear a gauze mask or a clean handkerchiefover his mouth and nose.

After smearing with the cream the burn shouldbe carefully wrapped in sterile lint and a bandage,or in a recently laundered clean towel.On no account should blankets be allowed to

come into direct contact with the burn (becausethey are frequently heavily contaminated withpathogenic organisms).

4. The cream should not as a rule be left on theburn for more than 2 days because there is a slightrisk of inducing dermatitis if left longer.

In special cases, e.g. in a small ship, or in ship-wrecked persons, this small risk will be ofno accountin comparison with the much greater risk of infec-tion if the burn is not treated.

5. The inclusion of a local analgesic in the first-aid cream is not recommended-for the followingreasons:

(a) It is unlikely to give sufficient relief for asevere burn, which will usually require morphia.

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FIRST-AID TREATMENT OF BURNS AND SCALDS

(b) The pain of many small burns is so transientas to need no analgesic.

(c) The relief of pain by local analgesics is un-certain, and often short-lived.

(d) There is some risk of toxic effects from theuse of local analgesics on a large burned area insusceptible individuals.

AcknowledgementsOur thanks are due to Mr. A. M. Clark, in whose

Department this work was carried out; and toDr. M. L. Thomson, Mr. W. C. Cawston, SisterDonald and Sister Bertram, who undertook muchof the routine work; to Dr. A. Tracy and the volun-teers collected by him who submitted to experi-mental burning; and to Dr. E. Collier who helped inthe clinical trials of local analgesics.

In connection with this work one of us (T. G.)received a special grant from the Medical ResearchCouncil.

REFERENCESBarnes, J. (1942). Lancet, I, 531.Colebrook, L. (1930). Ministry of Health, Appendix to

Interim Report of Committee on MaternalMortality and Morbidity.

, Clark, A. M., Gibson, T., and Todd, J. P. In thePress.

, Maxted, W. R., and Morris Johns, A. (1935). J.Path. Bact., 41, 521.

Hare, R. (1941). Lancet, I, 85.Jacoby, F. (1943). J. Physiol., 102.Leach, E. H., Peters, R. A., and Rossiter, R. J. (1943).

Quart. J. exp. Physiol., 32, 67.Thomas, J. C. (1941). Lancet, I, 433.Williams, R., Clayton-Cooper, B., Duncan, J. McK.,

and Miles, E. (1943). Ibid., 1, 522.

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