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.

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.

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.

1. 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.
2. 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:

1. Autografts: grafts taken from the patient's own body (auto = autos, meaning seM
2. Homografts: grafts taken from another individual of the same species (homo = omo, meaning similar, resembling)
3. 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.

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

1. when the patient's general condition is too poor;
2. when bleeding after excision is continuing;
3. 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.

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.