Pediatric Burns By Bradley J. Phillips

mandate a continued search for an approach to resuscitation which reduces the rate of edema formation.

The Burn Wound: Topical Treatment

In 1954, Liedberg and colleagues at the SRU noted that effective fluid resuscitation now kept many patients with greater than 50% TBSA burns alive past the 2-day mark, only to succumb later. Whereas previous authors had attributed these delayed deaths to “toxemia” or “exhaustion,” the presence of positive blood cultures, particularly in patients with large full-thickness burns, pointed at bacteremia of burn wound origin as the cause of death. This hypothesis was confirmed in the animal model of invasive pseudomonal burn wound infection developed by Walker and Mason.^57,58 At that time, however, no effective topical therapy had been identified.⁵⁹

Early descriptions of treatment of wounds are found in ancient Egyptian papyri. Several agents are recommended for the topical treatment of burns in the Ebers papyrus (1550 BC), ranging from boiled, ground goat dung in fermenting yeast, to copper filings and honey, to rubbing a frog warmed in oil on the wound.⁶⁰ Hippocrates (460-377 BC), whose influence permeated Western medicine for more than 5 centuries, mentioned several topical agents for the treatment of burns and seemed to favor old hog seam (lard) mixed with any or all of several other agents such as wax, bitumen and resin, and wine. Topical treatment was little changed in the 9th and 10th centuries, when Rhazes (850-932), the most famous Arabian physician of that time, proposed treating burns more gently by application of cold water or egg yolk in attar of roses. He is also credited with being the first to write about the use of animal gut for ligatures in operations. In the next century, Avicenna (Ibn Sina, 980-1037) is said to have recommended ice water for the treatment of burns. That treatment achieved no popularity in ancient times, but has elicited renewed interest in recent years.⁶¹

The application of various topical agents to the burn wound was continued by surgeons throughout the Middle Ages and Renaissance, with the stature of the physician, rather than data, determining the force of the recommendation. Ambroise Paré (1510-1590) is credited with a comparative trial showing that treatment with mashed onion and salt improved the healing of burns compared to an unspecified “control” substance. William Clowes and Richard Wiseman, the leading British surgeons of the 16th and 17th centuries, respectively, were also proponents of the onion treatment of fresh burns, as was Fabricius Hildanus in Germany.^61,62 A less irritating agent, carron oil, a 50/50 mixture of lime water and linseed oil, was widely used in topical dressings in the 18th and 19th centuries.⁶¹

The topical application of silver nitrate was initially, in concentrated form (lapis infernalis), used to remove granulation tissue from slow-healing burns and to produce a crust on the surface of fresh burns. Silver at that concentration caused severe pain in partial-thickness injuries and could, by itself, cause tissue necrosis. Johann Nepomuk Rust (1775-1840), a surgeon in the Prussian army, was an early advocate of dilute silver nitrate solution (0.2%) for the immediate treatment of burn wounds.⁶³ Unfortunately, a single application of the dilute solution of silver nitrate could not affect long-term control of microbial proliferation. Consequently, that use of silver nitrate did not win general acceptance.

In the colonial years of the United Sates, American physicians commonly traveled to Europe and England to “complete” their medical education. Consequently, burn care mirrored that practiced in Europe. In 1684, Dr Stafford of London gave Governor John Winthrop of Plymouth Colony a detailed recipe for the preparation of an ointment containing “rine of Eelder, Ssambucus, Ssempervive, and Mmosse” boiled in oil, to which was added barrow’s grease (lard from castrated male hogs). At the end of the 18th century, Mr John Vinal of Boston reported the beneficial effects of electricity on his burned thumb, and near the midpoint of the 19th century, Dr Samuel W. Francis described his invention of a glass glove which was used for continuous lime water irrigation of burns on extremities. In the very next year, Dr George Derby of Boston reported on the use of finely powdered dry earth for the successful treatment of burns of the leg and feet.⁶⁴

Throughout the remainder of the 19th century and during the early years of the 20th century, topical therapy of burn wounds changed little, with a wide variety of agents preferred by individual surgeons, without evidence of clinical effectiveness. In 1925, E. C. Davidson described the topical application of tannic acid to bind toxins and coagulate damaged tissue. The tannic acid treatment achieved transient popularity, but findings such as liver damage, impaired distal circulation (when used on the hands), and failure to reduce plasma losses, to prevent subeschar infection, or to improve patient survival led to its abandonment by the early 1940s.²² The triple-dye treatment (gentian violet, acriflavine, and brilliant green) of Aldrich had similarly transient popularity due to a lack of effect on patient outcome.²²

With the development of antimicrobial agents such as sulfonamides and other antibiotics in the 1930s and 1940s, it was only a matter of time until effective topical burn wound chemotherapy was developed. Initial trials of penicillin cream by Leonard Colebrook at the Birmingham Accident Hospital Burns Unit were frustrated by the rapid development of microbial resistance, and an early trial of