Specialized departments for the treatment of burns as we know them during the last decades have a long and varied history which resulted from the changing views on burn injuries and was associated with advances in medicine in general, in particular the development of critical medicine. In the Czech Republic there are three centres. the first one was founded in Prague in 1953, the second one in Ostrava in 1954, and the anniversary of third one in Brno we are celebrating in 2002.
In 1960 Winston Churchill said when addressing the College of Physicians " ....the longer you can look back, the further you can see forward..."
If we are to speak of burn injuries and the discipline of burn medicine we must remind that at the end of the 16th century in the small town of Payarne in Switzerland worked the surgeon Wilhelm Fabry (1560-1634) who published his experience with the treatment of burns in 1607 in the remarkable book "De Combustionibus" under his Latin name Guilhelmus Fabricius Hildanus as he came from Hilden near Dusseldorf. This was the first and up to the 20°' century the only publication which defined burn injuries, mentioned causes, prognosis and treatment. Fabricius was already 400 years ago aware that burn injuries are a systemic disease and not only a skin injury.
This view was unique and was encountered as late as in 1823 when W. Cumin (Edinburgh pathologist) based on postmortem findings in severely burnt patients concluded the some form of "internal inflammation" occurs. In 1953 D. H. Jackson (Birmingham surgeon) was concerned with this problem and called the condition "sick cell syndrome".
In 1957 M. Allgower (immunologist from Pratteln in Switzerland) considered as the cause of all complications and critical conditions in burn injuries the so-called "burn toxin" which he proved experimentally. In 1995 the same Allgower in his study "Burning the Largest Immune Organ" provides evidence that burn injuries are manifested by a systemic inflammatory response (SIRS) with severe immunodeficiency.
Let us come back with Prof. Burian to the beginning of the 20`I' century and his publication of 1947 where he writes that some problems of care in burnt patients have become the subject of special research in the Anglo-American world stimulated on the one hand by mass disasters in civilian life (in 1921 a fire in the Rialto theatre in Connecticut and in 1942 in in Cocoanut Grove in Boston) and specially the Second World War with a previously unheard of participation of the air force in fights and bomb attacks on English towns. This resulted in many casualties with burns not only among air force crews but also the civilian population. This was a mighty stimulus for establishing burn units founded in a number of British hospitals (Birmingham, East Grinstead, Edinburgh and others) where it proved possible to a certain extent to cope with shock, reduce infection due to aseptic nursing techniques and due to the discovery of sulphonamides and penicillin. Distinguished specialists on the British isles included A. B. Wallace, Colebrook and Sir Archibald McIndoe who devoted attention and care also to psychic rehabilitation.
The position on the European continent was however quite different. It was best recorded in an article published by Prof. Burian in the Czech medical journal Oasopis lékaru ceskych in 1952: "In our country so far not as much care is devoted to the treatment of burns as these severe injuries deserve. Frequently burns are treated in dermatological departments, children with burns are referred to paediatric hospitals and in some surgical departments burns are hospitalized among "septic cases" and are treated without strict aseptic provisions. This fatal error is a heritage of the old Austrian empire. There, similarly as in Germany, burns were referred to dermatological departments merely because the skin is first affected and the injury is most visible on it. At a time when this happened the knowledge on the pathology of burns and properties of the burn injury were negligible. Suppuration was considered an integral part of the clinical manifestation and nobody realized that it was due to treatment. Quite unscrupulously various ointments and oils were spread on unsterile cloths which were applied to the wound. The general shock of the organism was taken into consideration only in the sense that burns which affected more than 40 % of the body surface were considered fatal."
Care of patients with burns began to be separated from different disciplines according to the tradition of different European counries (from dermatology, surgery, plastic surgery) while in the United States burn medicine was since the seventies taught and controlled by a special Institute of Burn Medicine.
The increasing number of mass burn injuries during traffic accidents and terrorist activities led to the foundation of the European Burns Association. The European Burns Association (E. B. A.) was founded in May 1981 in Copenhagen by leading specialists of European burns departments incl. Czechoslovak ones. E. B. A. serves as a forum for spreading experience and knowledge, coordination of research (scientific, clinical, social), promotion of continuous training of all categories of workers of the burns team, it organizes European congresses and symposia and ensures international assistance in mass disasters where primary classification and immediate care is the task of specialists in burn medicine.
In severe thermal, electric, chemical and radiation injuries there are two tasks to provide comprehensive and continuous care to ensure survival and to ensure the quality of life by an interdisciplinary approach from the time of the injury to long-term, sometimes lifelong rehabilitation care incl. reconstructive surgery (which belongs to the duties of burn surgeons). Inadequate care complicates treatment, protracts it (and thus increases the costs) and due to permanent sequelae leads to so-called "social death", possibly suicide, as presented in publications abroad.
Adequate experience can be obtained only by concentrating this care in centres for the treatment of burns, equipped as regards space, instruments and staff, incl. trained burn nurses and physiotherapists.
From what has been said ensues why this discipline which is highly specialized and interdisciplinary cannot be ensured by surgeons or plastic surgeons who are preoccupied by a number of their own problems. Therefore they cannot. provide the above - essential - comprehensive and continuous care where according to Prof Burton's words "absolute humble patience" is needed.
R. Konigova M. D.
Faculty Hospital Kralovské Vinohrady
Srobarova 50
100 34 Praha 10
Czech Republic