Annals of the MBC - vol. 2 - n' 2 -
June 1989
HISTORICAL
LANDMARKS IN THE EVALUATION OF THE BURNS AND THE RELEVANCE OF PLASTIC SURGERY TO THEIR
TREATMENT
Polywatis G.E.
Athens University, Greece
SUMMARY. The increasing
knowledge about bums has given the impetus to develop more accurate methods of diagnosis
and treatment. In the past, men treating bums believed that post-bum tissue oedema ought
to be treated by avoiding fluid administration. Also numerous methods of treating bums,
which were in vogue for years, have been rejected or modified.
Up to the end of the 19th century, free skin grafting was limited to cover only traumatic,
or granulating areas, by small full thickness or by superficial epidermis grafts. But a
revolution occurred when it became clear that the dermal pad is the most important part of
the skin, and that the epithelium of the donor site regenerates from deep islands.
Consequently suitable instruments have been devised to cut thicker grafts in large areas.
Today the story of the burned patient begins at the minute of his accident, and should
continue to the day in which he finally resumes his place in society.
In addition to some other factors in the evaluation of the bums illness, the author
proposes a more correct and simple terminology for the different kinds of skin grafts used
today.
General Considerations
Historical background. Besides
some earlier monographs on burns, an important treatise was written by John Kentish of
Edinburgh. In 1797 he published an "Essay on Burns-, on the occasion of an explosion
of flammable gas in the mines. He advocated exposure therapy and he used topically or
alcohol, wine internally, laudanum for pain and a nourishing diet.
In 1850 it is believed that the first Bum House of the Royal Infirmary in Edinburgh was
built. Until the end of the 19th century there was no emphasis upon burns physiology, but
a wide variety of local elements were in vogue - carron oil, carbolic acid, mercury
bichloride, lead carbonate, zinc oxide ointment, gum arabic, lard, collodium, castor oil,
silver nitrate and many others.
Later picric acid, paraffin wax, and a spray of Dakin's solution were popularized. In 1925
Davidson introduced tannic acid, used for many years, which with silver, saline packs and
baths was introduced for Army Services in World War 11.
When later it was considered that 50-75% of the total number of deaths occurred from shock
within the first 48 hours, a great deal was accomplished in raising the standards of
treatment. Routine care changed radically, with the abandonment of tannic acid and other
types of chemical eschar agents.
Duringjhe same period, surgical physiology was revolutionized by changes in the knowledge
of fluid and electrolyte requirements, and initial plans for disaster care were outlined.
The famous Evans formula was given, and considerable discussion was devoted to colloid
therapy, plasma expanders, as well as to dextran, albumin, serum globulin etc.
Attention was given to shock and toxaemia and it was realized that both imply a state of
prostration and disorganization. Toxaemia means a gradual failure to withstand strain of
long duration, involving metabolic disorders due to toxic factors. In contrast shock
indicates an event of sudden onset which was originally attributed to the stunning
neurologic effects of any injury. It was later distinguished from syncope, because shock
subsequently progresses into a state of cardiovascular derangement. But there is not yet
one acceptable definition of shock; there are thus many theories to explain it.
Local infection. The experience gained in this subject concludes that the most
common and serious complication of the bum is infection, which is to a certain extent
inevitable. When organisms are embedded in hair follicles and sweat glands, they may
survive the sterilizing effects of heat. Also it was confirmed that septicaemia is rare
during the first few days, and that local infection is better controlled from the
beginning by a rigid routine of mechanical cleanliness than by topical agents.
The treatment of Pseudomonas infection continued to remain a problem, although some
clinics reported success with colymycin, polymixin and others.
Efforts have been made to develop suitable antisera against this organism.
Diagnosis. It is well known that the diagnosis of the condition of a burned patient
is estimated by the extent and by the depth of his injuries. Knowledge especially of the
depth of a bum is important for prognosis, as area for area, deep bums carry a higher
mortality.
In recent years attention has been focused on early diagnosis, so that deep bums may be
excised and grafted immediately.
Many years ago, and even in more recent times, different methods of diagnosis were
proposed, such as the blanching of the skin on pressure and the return of redness,
fluorescein, Van Gieson's stain, radioactive P., intravenous bisulphide blue, Evans blue,
fluorescein staining; recently a sensitive thermograph traced the infrared rays,
radiation, from burned skin, by measuring local temperature, which diminishes in
accordance with the depth of the bums. This is depicted by Polaroid.
Also, the computer is reported as a method of calculating the total burned body area, with
less error than conventional methods. All these methods have been developed for more
accurate diagnosis of the extent and the depth of bums, which are significant criteria for
proper treatment.
Some of these methods require expensive equipment and skill in using them, others a
proportional experience, while still others affect the body uncomfortably. That is why
some surgeons still regard the surface appearance of the burned patient, and yet more his
sensitivity to pin-pricking.
Skin grafting
Revolutionary achievements. Up
to the end of the 19th century, free skin grafting was limited to cover only traumatic or
granulating areas, by small full thickness or superficial epidermis graft. But a
revolution occurred when it became clear that the dermal pad is the most important part of
the skin, and that the epithelium of the donor site regenerates from deep islands.
Consequently suitable instruments, the dermotomes, have been devised to cut thicker grafts
in large areas.
Proposal for a better terminology of skin grafts. Before I describe skin grafting
methods for the treatment of bums, I thought it reasonable to discuss the terminology of
the grafts, suggesting simpler and more correct terms than the complex ones of today.
Many terms are used in skin graft nomenclature: heterograft, allograft isograft,
xenograft, zoograft and others, which are Greek words. Some of them have exactly the same
meaning, but they are used to indicate different kinds of grafts. For instance,
heterograft and allograft , both mean other (heteros-allos), isograft (isos) means equal,
xenograft (xeno) means foreign, zoograft (zoo) means animal, etc.
Unfortunately many surgeons in classical books and published papers, because of the
resemblance of these terms and the difficulty of distinguishing foreign words, use them in
different ways, thus causing confusion.
In actual fact, in plastic surgery, there are only two basic kinds of grafts: human grafts
and animal grafts.
- Human grafts: human grafts comprise two well-known
categories: those taken from the patient's own body, and those taken from another
individual. These are the human grafts.
- Animal grafts are those taken from animals. There is no
other kind of graft. Synthetic materials and skin substitutes (such as silicone, urethane,
polyester, polyvinylic, Biobrane, Omiderm and others) are not grafts, either in the form
of films or in the form of membrane. They are dressings, for protecting burned areas and
for helping the local and general condition of the patient. But they are not grafts.
In scientific terminology, graft is a
tissue originated from a living being, which when implanted in a living organism is
embodied and grows in its new place permanently or temporarily.
I thus propose to preserve for the existing 3 kinds of skin grafts the 3 following and
well-known terms:
- Autografts: grafts taken from the patient's own body (auto
= autos, meaning seM
- Homografts: grafts taken from another individual of the
same species (homo = omo, meaning similar, resembling)
- Zoografts: grafts taken from animals (zoo zoon, meaning anima/).
This terminology covers all the spectrum
of skin-grafts.
So the terms heterograft, isograft, allograft, xenograft, as well as heterologous,
isologous etc., should be abandoned, because they are confusing and complicating.
Skin substitutes used as dressings should be identified by the names of their synthetic
materials or by their commercial title.
I would suggest that if this terminology, which simplifies the classification of skin
grafting, is adopted by our Mediterranean Bums Club, it be proposed to the International
Society of Bums Injuries and to other Bums Societies. In this way, the service which the
Mediterranean Bums Club can offer in this important subject will be universally
invaluable.
Surgical treatment
Autografts. Nowadays early surgical excision and
immediate autografting is the method of choice in deep bums, because of its many
advantages, compared to the conservative procedures, autografting after spontaneous
separation, or bedside debridement.
A two-stage procedure is advisable after excision of sloughs
- when the patient's general condition is too poor;
- when bleeding after excision is continuing;
- when in doubt concerning the cleanliness of the viability
of the recipient area.
Homografts. In very extensive
bums, donor sites of the patient may be so limited that adequate early skin cover is
impossible without the addition of homografts (taken from another living individual, or
post-mortem. Such grafts provide a temporary cover but they are helpful).
Zoografts. Mostly bovine and
porcine skin grafts are in use; the latter have proved more effective and are widely used.
Amniotic membrane. This is an old
but helpful dressing. The method proposed by Prof. Masellis and his collaborators in the
Ist meeting last year, by its meticulous preparation, seems to have many advantages.
Synthetic materials and cultured
skin. Many synthetic skin substitutes have been proposed and applied as temporary
dressings, with the names Synkryt, Aloxan, Epigard, Syspar-derm (a bilaminated polyrethane
based on polyester), collagen, Biobrane (silicone rubber membrane), Omiderm (a new
synthetic membrane made of a hydrophylized polyurathane substance).
In addition there is plasticized
polyvinyl-chloride film, which originally was used for wrapping foodstuf[s.
There is also cultured skin as a biological material to cover open burn surfaces, taken
from individuals or animals.
All those etTorts have proved helpful and should continue in the future for a better
preparation of autografting.
Conclusions
Today the story of the burned patient begins at the
minute of his accident, and should continue up to the day he finally resumes his place in
society. No doubt a considerable percentage of the progress of plastic surgery and its
recognition as an independent surgical speciality is due to the efforts to deal with bums
in the acute stage, as well as in the post-bum period, because of the consequent
deformities. For this reason and to repay for its contribution, the burn illness should be
one of the main concerns of every plastic surgeon, since any service given to the burned
patient increases the prestige of plastic surgery. Finally, the proposed terminology of
auto-, homo- and zoografts simplifies classification and understanding, covers all the
spectrum of skin grafts, and relieves us of the confusion resulting from the unsuccessful
use of other terms. Therefore this terminology deserves to be universally adopted.
RÉSUMÉ. Les connaissances
toujours en accroissement à propos des brûlures ont permis de développer des méthodes
plus précises de diagnose et de thérapie.
Dans le passé, on pensait que, pour traiter les brûlures, il fallait traiter l'oedème
des tissus brûlés en évitant l'administration des liquides. Beaucoup d'autre méthodes
pour le traitement des brûlures, employées pendant une longue période d'années, ont
été repoussées ou modifiées. Jusqu'à la fin du dix-neuvième siècle, on employait la
greffe cutanée libre seulement pour couvrir les zones traumatiques ou granuleuses, avec
dq5 petites greffes à toute épaisseur ou des greffes épidermiques superficielles.
Nfais toutes les théories ont été bouleversées par la découverte que le coussin
dermique est la partie la plus importante de la peau, et que l'épithélium du site
donneur se régénère depuis les îlots profonds. Conséquemment on a créé des
instruments appropriés pour pratiquer des incisions afin d'avoir des greffes plus
épaisses et avec étendue plus large.
Aujourd'hui la thérapie du brûlé commence depuis la première minute après la lésion,
et elle doit continuer jusqu'au jour où il reprend sa place dans la société.
L'Auteur indique d'autres facteurs pour l'évaluation des brûlures, et il propose une
terminologie plus exacte et plus simple pour les techniques diverses de greffe cutanée
par rapport à la terminologie utilisée couramment.
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