BritishJournal of Plastic Surgery (1977), 30, ZI~W,IT

HISTORICAL LANDMARKS IN THE TREATMENT OF BURNS

By MOGENS THOMSEN, M.D., Ph.D. Department of Plastic Surgery and Burns Unit, Hvidovre Hospital, Copenhagen, Denmark

SINCE man first learned to make fire, burns and scalds have been one of his commonest injuries. It follows, therefore, that even the earliest medical texts and certainly all surgical treatises have a section on burns and their treatment. The material available to the historian is immense, and ruthless selection is needed for a coherent account. I have limited myself to the earliest writers who probably carried on the methods of their illiterate predecessors and to those who were responsible for specific innovations.

Goos, unguents, salves and magic. The most popular local application has always been some kind of bland semi-solid, and still is today in the form of creams and ointments. Their ease of application, their initial cooling effect and their removal without sticking commend them to both patients and physicians. Some of the main varieties are described in the most well-preserved of the medical papyri, written about 1550 B.C., but only discovered 100 years ago by Professor Ebers from Leipzig where it is still to be seen. It recommends black mud for the frrst day’s treatment, boiled cow dung for the next and a later choice of 3 different goos: acacia resin mixed with barley dough stirred in oil; bull’s fat boiled with papyrus; colocynth mixed with red ochre and con- taining copper splinters (Deines et al., 1958).

Animal fats and dung were the most popular. The old Hindu surgeon Sushruta (cu. Soo B.C.) used tmguents of clarified butter mixed with red ochre or the bark of a fig tree (Bhishagratna, 1963). Hippocrates (ca. 400 B.C.) boiled oak-tree roots to a thick cream in wine and water, added old lard, onion slices, resin and asphalt and applied the mixture warm (Adams, 1939). Pliny the Elder (A.D. 23-79) recommended among other things hare’s and she-goat’s dung. He also said that burns could be treated with glue preferably made from the ears and genitals of bulls. Pliny, however, had so many local applications for burns ranging from decoctions of cyclamen roots to hard-boiled yolks of eggs mixed with- rose oil, that he may well have had doubts of the worth of any individual preparation. He was a great scientist and collected all the wisdom of antiquity in his Natural History of 37 books (Rackham et al., 1938-63). His favourite treatment for burns seems to have been the ash of pig’s bristles from well worn-out brushes of plasterers beaten up with pig’s fat, wax and bone marrow.

It would be tedious and not a little revolting to detail all the hundreds of variations on this theme. The bland base and the magical ingredients are common to most. The popular “white ointment” which replaced the most repulsive salves and was used throughout the Middle Ages was introduced by Rhazes (850-923); it was composed of white lead, oil of roses and wax @hazes, 1556).

Cooling lotions. The dramatic effect of cold applications in relieving the pain of an acute burn must have been known for centuries in countries where it was readily available, but it was the Arabian School of Medicine which first wrote about it. Rhazes advised rose water cooled with snow, and Avicenna (980-1037) ice water (Avicema, 1507). The present era, however, really began with Sir James Earle (1755-1817) who describes several cases of burns which he had treated with ice as an antidote (Earle, 1799).

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HISTORICAL LANDMARKS IN THE TREATMENT OF BURNS 213

FIG. I. The water-bed used by von Hebra, Vienna, 1861.

Dzondi (1770-1835) in Germany was the first to carry out controlled experiments in dogs which were scalded and then treated with cold water. He even experimented with his own index finger and movingly describes his effort to keep the finger long enough in boiling water to scald it (Dzondi, 1816).

Heat. Not all surgeons believed that cool applications were appropriate. Ambroise Pare (rsro-ISgo) did not hold with the principles of contrariety and so believed they should be avoided and indeed claimed that the pain in a burn would diminish if the part was approached to the fire (Par& 1582). This idea of burning out the burn was fairly widely held at that time and is referred to in Shakespeare’s King John (1602), where Cardinal Pandulph says to Ring Philip:

“And falsehood falsehood cures as fire cools fire Within the scorched veins of one new-burned.”

(Act 3, scene I)

Fabricius Hildanus (1560-1634)~ or Fabry of Hilden, who wrote the first book devoted entirely to burns “de Combustionibus” (16o7), warned against cooling burned skin which he felt would harden like fat when it is cooled and thus shut in the moisture.

Baths. Although the Romans had highly developed hot baths, I have found no reference that they ever used them for treating burns and it was only when sophisticated plumbing technology evolved in the 19th century that bathing either intermittently or continuously became a feasible treatment for burns. The outstanding proponent of this technique was von Hebra (1816-1880) the famous Viennese dermatologist. He designed

214 BRITISH JOURNAL OF PLASTIC SURGERY

and had constructed a wooden tub (Fig. I) in which the patient was immersed in con- tinuously warmed water often for weeks. The water was changed daily (Hebra, 1861). Since then baths have enjoyed only occasional popularity; the large number of staff required to organise them efficiently is rarely available.

Exposure. The 19th century saw another local treatment emerge. Copeland of Alabama in 1887 first described the open or exposure method for treating burns. In Switzerland, Bernhard (1904) mentioned the favourable influence of the climate at high altitudes on wound healing in general and compared the open treatment of wounds with the manufacturing process of the delicious ‘Biiindner Fkisch”. Subsequently exposure was also recommended by Sneve (1905) and John (Igro), who both used it in several cases of quite extensive burns and stressed the improved comfort of the patients. Later the method seems to have lost favour because of the unavoidable infection. As is well known, the principle was resuscitated in 1947 by the late Alastair B. Wallace in Edinburgh (Wallace, 1948) and, largely as a result of his persuasive teaching, is still widely used.

Contractures. Since ever there were deep burns there must have been burn contractures, and Valesco of Montpellier in France in his textbook of surgery of 1480 described how to avoid syndactyly in hand burns. Until the advent of free skin grafting their correction was difIicult or impossible, but Fabry of Hilden illustrates how he tried to overcome a dorsal hand and linger contracture by dividing the scar with transverse incisions and splinting to avoid recurrence (Fig. 2). He also advised massage with ointment “as a tanner stretching hides” for lesser contractures (Fabricius, 1607).

During the renaissance of plastic surgery in the first half of the 19th century, several

‘2 $0 OBSHRVATIONES

0 2a

FIG. 2. a and b, Finger-splint used by Fabry of Hilden in 1607 to correct a bums contracture.

HISTORICAL LANDMARKS IN THE TREATMENT OF BURNS 215

FIG. 3 (Left). Wood-cut from the works of Paracelsus, 1536, to illustrate the risk of burning when using gunpowder.

FIG. 4 (Right). Amman’s thesis on burns, Leipzig, 1658.

local flaps were designed to correct burn contractures. Probably the earliest and certainly one which was later copied on both sides of the Atlantic was that of Mutter (1843). It was not, however, until 1869 when Reverdin (r8@-1929) had published his skin- grafting technique in Paris that Pollock (x817-1897) on the other side of the Channel used it for burns (Pollock, 1871).

Surgery. A part of the sacred Ayurveda writings from about 8oo B.C. make up the collected works of Sushruta and is called the Samhita. Here it is recommended to debride severe burns with “loosed skin and flesh” (Bhishagratna, 1963). Fabry of Hilden in x6o7 recommended that blisters should be cut to avoid the infection which he had often ob- served to increase the depth of the burns. In very deep burns he made incisions to let the moisture escape, as otherwise gangrene and infection would supervene; these were the first recorded “escharotomies”.

The first to suggest excision proper of the burnt tissue was Lustgarten (r8gr), but Wihns (1901) was the first to carry it out; he even grafted the excised areas. In Vienna, Weidenfeld and Zumbush (1905) performed the excision in the acute period either on admission or during the first 3 days.

Fluids for shock. The first description of the clinical symptoms of a typical burn case is given by Sushruta. The enormous thirst and the fever are mentioned as character- istics. It was not, however, until Baron Guillaume Dupuytren (1777-1835) in Paris gave

216 BRITISH JOURNAL OF PLASTIC SURGERY

his most elegant lectures that the whole clinical picture of a fatal burn was related to the post-mortem fkldillgS (Dupuytren, 1832-34).

Sir John Eric Erichsen (r818-18g6), professor of surgery in London, but born in Copenhagen, noticed at post-mortem examination of patients having died from burns the congestion of the internal organs, and suggested that the treatment should be by blood-lettings and diuretics (Erichsen, 1843). In Paris, Baraduc (1862) demonstrated that the blood after a burn loses so much fluid that it grows thicker and has difficulty in passing through the smaller vessels; the treatment therefore should be drinks, enemas and baths. In Italy, finally, Tommasoli (r857-1904) started to treat patients with severe burns by saline infusions (Tommasoli, 1897).

Mass burning disasters. The first description of a mass disaster of burns was given by Georgi (1768-1834) in his report on the tie in the fireworks laboratory of Dresden (Georgi, 1828). He describes his treatment of the victims and gives an excellent account of the symptoms of the untreated shock, as well as the post-mortem findings in cases with lung burns. It should be remembered, however, that burning was a feature of early gunshot wounds and accidents with gun powder were not uncommon (Fig. 3). Paracelsus (14g3-1541) stressed the importance of cooling the bullet while still in the tissue, and mentioned the additive effect of the cauterisation caused by the sulphur used in the powder (Paracelsus, 1536). War burns were also dealt with by the famous English surgeon William Clowes (1~40-1604) whose book, published in 1588, had the delightful title: “A prooved practice for all young chirurgians concerning burnings with gun-powder, and wounds made with gunshot, sword, halbard, pike, launce, or such other”.

Textbooks on burns. The frrst monograph on burns treatment was written in 1607 by Fabry of Hilden. In 1622, there followed an extensive survey by Hornung and another in 1681 by van Alberding. The first thesis on burns was published in Leipzig in 1658 (Fig. 4). It is dedicated to Christian Lange (1619-1662) who was the dean of the medical faculty. The name of the author, Amman (1634-x691), appears further down. By an often repeated mistake, such books have later been cited under the more accentuated names of the deans, and can be difficult to trace.

Conclusion. The basis for this little survey is more extensive studies carried out over some years. It has thereby become evident that the treatment of burns through the centuries has followed the main principles used for the treatment of wounds in general, including cold water and warm baths. The growth of scientific knowledge throughout the 19th century gradually led to a more logical treatment of the local and systemic symptoms of burns.

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