original article: 2014 aba paper
Burn Care in the 1800s Eleanor Hattery,* MD, Tiffany Nguyen, BA,* Aaron Baker, MD* Tina Palmieri, MD†‡ The 1800s show a wide range of both understanding and misinterpretation of the pathophysiology and treatment of burns. The objective of this paper was to describe the key advancements in the study and treatment of burns in the 1800s. We reviewed primary and secondary sources of ancient to modern burn care manuscripts. Prior to the 1800s, burn care was different iterations of poultices and oils placed over acute burns in the hope the patient would survive. The 1800s showed the discoveries of the Curling and Marjolin’s ulcers as well as the first understanding of inhalation injury and advancements in skin grafting, leading to further understanding of the disease process. (J Burn Care Res 2015;36:236–239)
No cases demand more urgently immediate and judicious treatment than burns, and yet perhaps in no cases are more ignorance and incompetence shown by too large a number of medical men. —Ashhurst 1862.1 The treatment of burn injury has varied over the centuries. Wilhelm Fabry’s 1607 publication De Combustionibus was the first book devoted to the subject of burn care and the first to describe a three-stage classification of burns.2 However, it was not until the 1800s that advancements in the study and treatment of burns such as skin grafting and new discoveries on the pathophysiology of burns became common. At this time, surgery also became a part of the treatment of burn injury. This manuscript will explore burn treatment evolution during the 1800s and describe the discoveries of the era. From acute treatment of burns to the discovery of Curling’s ulcers and the first western descriptions of skin grafting and reconstructive surgery, the 1800s show a wide range of both understanding and misinterpretation of the pathophysiology of this relatively common phenomenon.
From the *University of California, Davis; †Regional Burn Center, University of California Davis Medical Center, Sacramento; and ‡Shriner’s Hospital for Children—Northern California, Sacramento. Address correspondence to Eleanor Hattery, MD, UC Davis Surgery Resident, UC Davis Regional Burn Center, 2315 Stockton Boulevard, Sacramento, California 95817. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000112
236
Discussion The epidemiology of burns has remained fairly constant throughout history. The common causes of burns in the 1800s included: scalds from cooking or industry; children’s, women’s or the elderly’s clothing catching fire; and intoxication among those burned or asphyxiated.3 A death due to sunburn was also described.4 Gunpowder was also a source of burns coming from both shelled and unshelled sources. Dr. Lonsdale described the differences between gunpowder burns and those from more conventional means especially when the powder was not confined in a casing. Dr. Lonsdale noted that the powder could remove eyebrows and lashes without leaving powder marks or involving the eye surface, which was rare for face burns of the time which often left corneal ulcerations.5 In the 1800s, burn pathophysiology was thought to occur in three stages. The period of congestion occurred in the first 48 hours, followed by the period of inflammation from day 2 to 14, followed by the period of suppuration.6 Baron Dupuytren added a fourth period: exhaustion.4 He advocated that burns affect different skin areas differently—severe burns were less likely on the areas of the exposed skin, pointing to the thin epidermis of the areas habitually covered. He also suggested that there were six degrees of burns, the fifth being those involving structures such as fascia and muscle. The sixth degree was described as being a carbonized, easily breakable limb as in the case of a young man who ran through a foundry having put his foot through a trench where fused metal was passed and on removal had no foot or lower leg and had felt no pain.7
Journal of Burn Care & Research Volume 36, Number 1
Postmortem pathologic examination of burn victims was common in the 1800s. Dr. Long in the 1840s described examinations of burn victims who died in different intervals after the initial injury. In almost every case of those with extensive burns, those who died within 48 hours had lesions in one or more of the three great cavities (thorax, abdomen or head). A death at 36 hours was described as having a firm dry brain, engorged lungs, and mucositis with miliary ulceration of the mucus membranes with turbid urine—a description we now associate with death by shock. Later burn deaths were attributed to tetanus, and pneumonias, which still pose a threat to present-day burn victims. The first duodenal ulcer was also noted in Long’s findings.8 This was followed by Curling in 1842 who wrote a large series on duodenal ulcerations after burns, which have led to this lesion being referred to as the Curling’s ulcer.9 In 1828, a French surgeon named Marjolin wrote about warty changes on chronic ulcers of the legs. Dupturyn expanded the description and Byron and Smith who described these ulcers from arising from burns and other traumas confirmed the malignant transformation later in the 19th century.10 Fluid resuscitation was unheard of in the 19th century. Decroz and Breshet believed in cutaneous perspiration or the need to lose water by the skin. They performed experiments on rabbits in which the rabbits were coated with gum-lac or a mixture of resin and salt (which would prevent moisture from being exchanged with the environment). It was believed that since the skin having been burned would not be able to exchange water with the outside world, which the other tissues, namely GI tract and lungs would then have to start secreting more fluids. Mr. Erichsen suggested the employment of diuretics and guarded blood letting for those with greater depth burns to rid the body of the excess fluid and when encephalitis begins manifesting that the treatment should be venesection or leeching.6 Dupuytren also agreed with bleeding and recommended placing compresses of cerate on the burns.4 By 1862, Dr. Ashhurst proposed the first relatively modern understanding of burns. “The burn is to be looked upon as a constitutional more than a local affection.” He stated that the caregivers should put patients to bed and cover them with blankets, indicating that he understood the patients would get cold, along with stimulants, as the first danger is “shock.” At that time if half or even one third the body surface was involved in the burn it was almost assuredly fatal. He also noted that the most universal accompaniment of burns was extreme thirst, stating, “I am in the habit of allowing small pieces of ice to be held in the mouth or may give small quantities of carbonic acid water but on no
Hattery et al 237
consideration permit more than a mouthful of water to be drunk at once.”1 Minimal fluids if any at all were given. In 1876, Inspector General Smart, having taken care of a large number of burns during an occupation of Canton, made a note that constipation was a great prognostic value.11 He also mentioned the Thunderer explosion, an ironclad ship whose boiler exploded only 400 yards off shore killing more than 40 people, mostly from scalds.12 From his observations from these two events, he identified that 80 square inches of burns was a threat to life. He also stated that 350 square inches from steam or 250 from gunpowder were almost assuredly fatal. Smart used his observations to determine that if the scalds involved the fauces (pharynx) or primary air tubules of those men making it to the shore these were the injuries of most fatal importance. This could be considered the first understanding of the importance of inhalation injury in burns. On the subject of the application of topical agents on burns, the bulk of the writing focused on simple recipes rather than additional instructions. In 1812, the first study was performed to determine which regimens were best. Dr. James Bigelow of Boston, professor at Harvard, designed a case control study using a rabbit ear scald model to compare and contrast the current recommendations for burn remedies. He compared cold ice water and warm water as well as the application of olive oil and limewater (calcium hydroxide, in combination with sodium bicarbonate and sodium carbonate form what is now Dakin’s solution a standard in topical burn care)13 vs a liniment of turpentine and followed the rabbits over time. Conclusions drawn from these experiments included that, “In more violent burns, attended with blisters and acute pain, a permanent relief is to be expected only from suppuration. This is promoted as in other cases of suppurative inflammation, not by acrid stimulants, not by snow and ice but by mild emollients and warm fomentations or poultices. … Perhaps no application is better than a liniment of limewater and oil.”3 Bigelow’s findings were not universally accepted. Members of different societies described remedies that they tried and worked. For example, Mr. Peppercorne described his use of lint soaked in a saturated solution of the carbonate of soda saying that it relieved pain possibly by neutralizing the acidulous quality of the perspiration.14 Smart found the oil and limewater hard to place on the head, face, and neck, so substituted with carbolic oil and a dusting of zinc, magnesia, and starch sifted when moisture appeared to create a kind of mask. He noted that this only caused trouble on the ear where abscesses were bothersome.11
Journal of Burn Care & Research January/February 2015
238 Hattery et al
The treatment of pain was rarely discussed in these historical works except with regard to which ointment seemed to sooth. Dupuytren believed, Brandy and opium are the remedies most to be relied on in the treatment of burns. “Brandy should be given in the form of milk-punch as furnishing with digestible food. Preparations of carbonate of ammonia and in doses of five grains made to an emulsion with gum and sugar may be given as often as every half an hour.”4 Smart would give the patients stimulants: sago and beef tea, anodynes of opium and chloral hydrate, chloroform to allay stomach irritation. After rallying, patients received beef tea, night and day limewater with milk to allay irritability of the stomach, and laxatives on the third day to relieve constipation. Animal food was then given such that the healing process would go on rapidly.11 There was no mention of patients requiring more nutrition secondary to their burns.
Surgical Treatment of Burns Modern burn treatment consists of the early tangential excision and grafting and the 1800s showed great advancements in the field of skin grafting.15 The father of plastic surgery, Sushruta, used skin grafts, as early as 600 BCE in India, to reconstruct noses lost to syphilis or punishment.16 Only rare anecdotal reports of skin transfers to noses were reported in Europe until the late 1700s. Skin grafts were further studied in 1804 by Guiseppe Baronio when he wrote Degli Innesti Animali where he first described experimental autologous skin transplant in a ram.17 Figure 1
shows his book’s illustration. Bunger further studied this in 1823, describing transplantation of the skin to human noses. M. Reverdin brought full thickness pinch grafts, to the world’s attention in 1869. He described removing skin from one arm and placing it in the granulating tissue of the other, thus creating small islands of skin on large burns with quick healing donor sites. Others repeated his work after hearing the account and obtained varied success.18 The 1870s had a broadening of skin graft techniques with Thiersh advocating for razor thin grafts and Ollier proposing a deeper thickness graft including part of the dermis.19 Split thickness grafts able to cover larger wounds consequently earned them the name Ollier-Thiersh grafts.20 Thiersh is also credited with increased aseptic technique in the fields of surgery.21 While these grafts were mostly done on chronic wounds and burns it laid the foundation for the future of burn care today. Reconstructive surgery for the cicatrix (scarring/ contracture) of burns was somewhat closer to what we have available today. As early as 1812, the release of burn contractures was alluded to in Dr. Bigelow’s work where, “it is necessary to divide the newly formed skin in different places, thus allowing it to expand.”3 In 1841 Dr. Mutter, a professor of surgery at Jefferson Medical college of Philadelphia, described burns of the neck constricting movement and the creating of a flap in order to correct the deformity. He was able to repeat the surgery on other patients.22 Figure 2 shows his illustrations over time of his first patient. The success of these skin grafts, flaps, and burn survival in general need to be taken into the context
Figure 1. From Degli Innesti Animali illustration of ram after skin grafting.17
Journal of Burn Care & Research Volume 36, Number 1
Hattery et al 239
Figure 2. Illustration from Mutter’s cases of deformity of burns relieved by operation.22
of the era. The first article on asepsis was published by Lister in 1867. “Antiseptics were used primarily to clean the environment, not surgical instruments, bandages, or wounds… at operation the surgeon might strop his knife on his boot or go so far as to hold blade between his teeth.”23 Ligation of bleeding vessels was a new technique to surgeons and cautery was fast falling out of favor for more modern tourniquets or suture techniques. Smart, in the Lancet, notes that he attempted to “maintain the highest possible degree of atmospheric purity, almost every known deodorant was used… sprinkled on floors from watering pots and on sheets hung round the offensive beds.”11 The idea of anesthesia, the use of inhaled gases, of ether and chloroform was another evolving area of medicine. It was not until the second half of the 19th century that surgical procedures regularly included the use of anesthesia. With orotracheal intubation having not been described until well after the civil war.24
Conclusion While there was many missteps in the evolution of burn care, there were also great achievements in the 1800s. The discoveries of the Marjolin’s and Curling’s ulcers showed improved understanding of the pathophysiology of burns. The idea of fluid resuscitation came quickly there after in 1905 with the first article by Haldor Sneve but the current recommendations were not brought about until 1968 and the Parkland Formula.25 Skin grafting techniques continued to improve but not until the late 1960s did they become significant in the acute treatment of burns. Inhalation injury had been noted to be a worse prognostic value but orotracheal intubation was still in its infancy. Ashhurst was correct in saying that burns required urgently immediate and judicious treatment; however, the 1800s proved that surgeons of the time tried very hard to correct their ignorance and incompetence on the subject.
References 1. Ashhurst J. On burns. Am J Med Sci 1862;XLIIL. 2. Naylor IL, Curtis B, Kirkpatrick JJ. Treatment of burns scars and contractures in the early seventeenth century; Wilhelm Fabry’s approach. Med History 1996;40:472–86. 3. Bigelow J. Nature in disease illustrated. Boston, Massachusetts: Ticknor and Fields; 1812. 4. Dupuytren M. Cases of burn. London Med Gazette 1833;11:742–3. 5. Lonsdale E. Burns by gunpowder. London Med Gazette 1833;81:696–7. 6. Erichsen J. On the pathology of burns. London Med Gazette 1843;XXXI:544. 7. Dupuytren B. On burns. London Med Gazette 1833;2. 8. Long J. On the post-mortem appearances found after urnbs. London Med Gazette 1840;25:743–50 9. Curling TB. On acute ulceration of the duodenum in cases of burn. [Manuscript of lecture read 28 June, 1842.] 1842:260. 10. Kingsley Opara ICO. Marjolin’s ulcers: a review. Niger Health J 2011;11:107–11. 11. Inspetor General Smart CBRN. On burns by gunpowder and scalds by steam. The Lancet 1976;1876:421. 12. Chesneau R, Kolesnik E. Conway’s all the world’s fighting ships 1860–1905. UK: Conway Maritime Press; 1979. 13. Lime water. Available from http://medical-dictionary.thefreedictionary.com/lime+water; accessed February 9, 2014. 14. Peppercorne F. Treatment of burns. London Med Gazette 1843–44;I. 15. Janžekovič Z. Once upon a time … how west discovered east. JPRAS 2008;61:240–4. 16. Bhishagratna KKL. The Sushruta Samhita—an English translation based on original Sanskrit texts. Calcutta, India: Kavirah Kunja Lal Bhishagratna; 1916. 17. Baronio G. Degli Innesti Animali. Milan: Dalla Stamperia e Fonderia Del Genio. 1804. 18. Power H. A biennial retrospect of medicine, surgery and their allied sciences. London: Dalla Stamperia e Fonderia Del Genio; 1870. p 49-61. 19. Ollier L. Greffes cutanees ou autoplastiques. Bull de L’Acad de med 1872;36:234. 20. Dailey G. Current medical thought. J National Med Assoc 1913;5:265. 21. Klasen H. Application of the principles of Thiersch in skin grafting, and further developments (1886–1900). History of free skin grafting. Berlin Heidelberg: Springer; 1981. p. 61–101. 22. Thos D, Mutter M. Cases of deformity from burns, relieved by operation. Philadelphia: Merrihew&Thompson; 1843. 23. Blaisdell FW. Medical advances during the Civil War. Arch Surg 1988;123:1045–50. 24. Robinson DH, Toledo AH. Historical development of modern anesthesia. J Invest Surg 2012;25:141–9. 25. Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns 2009;35:4–14.
Burn Care in the 1800s Eleanor Hattery,* MD, Tiffany Nguyen, BA,* Aaron Baker, MD* Tina Palmieri, MD†‡ The 1800s show a wide range of both understanding and misinterpretation of the pathophysiology and treatment of burns. The objective of this paper was to describe the key advancements in the study and treatment of burns in the 1800s. We reviewed primary and secondary sources of ancient to modern burn care manuscripts. Prior to the 1800s, burn care was different iterations of poultices and oils placed over acute burns in the hope the patient would survive. The 1800s showed the discoveries of the Curling and Marjolin’s ulcers as well as the first understanding of inhalation injury and advancements in skin grafting, leading to further understanding of the disease process. (J Burn Care Res 2015;36:236–239)
No cases demand more urgently immediate and judicious treatment than burns, and yet perhaps in no cases are more ignorance and incompetence shown by too large a number of medical men. —Ashhurst 1862.1 The treatment of burn injury has varied over the centuries. Wilhelm Fabry’s 1607 publication De Combustionibus was the first book devoted to the subject of burn care and the first to describe a three-stage classification of burns.2 However, it was not until the 1800s that advancements in the study and treatment of burns such as skin grafting and new discoveries on the pathophysiology of burns became common. At this time, surgery also became a part of the treatment of burn injury. This manuscript will explore burn treatment evolution during the 1800s and describe the discoveries of the era. From acute treatment of burns to the discovery of Curling’s ulcers and the first western descriptions of skin grafting and reconstructive surgery, the 1800s show a wide range of both understanding and misinterpretation of the pathophysiology of this relatively common phenomenon.
From the *University of California, Davis; †Regional Burn Center, University of California Davis Medical Center, Sacramento; and ‡Shriner’s Hospital for Children—Northern California, Sacramento. Address correspondence to Eleanor Hattery, MD, UC Davis Surgery Resident, UC Davis Regional Burn Center, 2315 Stockton Boulevard, Sacramento, California 95817. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000112
236
Discussion The epidemiology of burns has remained fairly constant throughout history. The common causes of burns in the 1800s included: scalds from cooking or industry; children’s, women’s or the elderly’s clothing catching fire; and intoxication among those burned or asphyxiated.3 A death due to sunburn was also described.4 Gunpowder was also a source of burns coming from both shelled and unshelled sources. Dr. Lonsdale described the differences between gunpowder burns and those from more conventional means especially when the powder was not confined in a casing. Dr. Lonsdale noted that the powder could remove eyebrows and lashes without leaving powder marks or involving the eye surface, which was rare for face burns of the time which often left corneal ulcerations.5 In the 1800s, burn pathophysiology was thought to occur in three stages. The period of congestion occurred in the first 48 hours, followed by the period of inflammation from day 2 to 14, followed by the period of suppuration.6 Baron Dupuytren added a fourth period: exhaustion.4 He advocated that burns affect different skin areas differently—severe burns were less likely on the areas of the exposed skin, pointing to the thin epidermis of the areas habitually covered. He also suggested that there were six degrees of burns, the fifth being those involving structures such as fascia and muscle. The sixth degree was described as being a carbonized, easily breakable limb as in the case of a young man who ran through a foundry having put his foot through a trench where fused metal was passed and on removal had no foot or lower leg and had felt no pain.7
Journal of Burn Care & Research Volume 36, Number 1
Postmortem pathologic examination of burn victims was common in the 1800s. Dr. Long in the 1840s described examinations of burn victims who died in different intervals after the initial injury. In almost every case of those with extensive burns, those who died within 48 hours had lesions in one or more of the three great cavities (thorax, abdomen or head). A death at 36 hours was described as having a firm dry brain, engorged lungs, and mucositis with miliary ulceration of the mucus membranes with turbid urine—a description we now associate with death by shock. Later burn deaths were attributed to tetanus, and pneumonias, which still pose a threat to present-day burn victims. The first duodenal ulcer was also noted in Long’s findings.8 This was followed by Curling in 1842 who wrote a large series on duodenal ulcerations after burns, which have led to this lesion being referred to as the Curling’s ulcer.9 In 1828, a French surgeon named Marjolin wrote about warty changes on chronic ulcers of the legs. Dupturyn expanded the description and Byron and Smith who described these ulcers from arising from burns and other traumas confirmed the malignant transformation later in the 19th century.10 Fluid resuscitation was unheard of in the 19th century. Decroz and Breshet believed in cutaneous perspiration or the need to lose water by the skin. They performed experiments on rabbits in which the rabbits were coated with gum-lac or a mixture of resin and salt (which would prevent moisture from being exchanged with the environment). It was believed that since the skin having been burned would not be able to exchange water with the outside world, which the other tissues, namely GI tract and lungs would then have to start secreting more fluids. Mr. Erichsen suggested the employment of diuretics and guarded blood letting for those with greater depth burns to rid the body of the excess fluid and when encephalitis begins manifesting that the treatment should be venesection or leeching.6 Dupuytren also agreed with bleeding and recommended placing compresses of cerate on the burns.4 By 1862, Dr. Ashhurst proposed the first relatively modern understanding of burns. “The burn is to be looked upon as a constitutional more than a local affection.” He stated that the caregivers should put patients to bed and cover them with blankets, indicating that he understood the patients would get cold, along with stimulants, as the first danger is “shock.” At that time if half or even one third the body surface was involved in the burn it was almost assuredly fatal. He also noted that the most universal accompaniment of burns was extreme thirst, stating, “I am in the habit of allowing small pieces of ice to be held in the mouth or may give small quantities of carbonic acid water but on no
Hattery et al 237
consideration permit more than a mouthful of water to be drunk at once.”1 Minimal fluids if any at all were given. In 1876, Inspector General Smart, having taken care of a large number of burns during an occupation of Canton, made a note that constipation was a great prognostic value.11 He also mentioned the Thunderer explosion, an ironclad ship whose boiler exploded only 400 yards off shore killing more than 40 people, mostly from scalds.12 From his observations from these two events, he identified that 80 square inches of burns was a threat to life. He also stated that 350 square inches from steam or 250 from gunpowder were almost assuredly fatal. Smart used his observations to determine that if the scalds involved the fauces (pharynx) or primary air tubules of those men making it to the shore these were the injuries of most fatal importance. This could be considered the first understanding of the importance of inhalation injury in burns. On the subject of the application of topical agents on burns, the bulk of the writing focused on simple recipes rather than additional instructions. In 1812, the first study was performed to determine which regimens were best. Dr. James Bigelow of Boston, professor at Harvard, designed a case control study using a rabbit ear scald model to compare and contrast the current recommendations for burn remedies. He compared cold ice water and warm water as well as the application of olive oil and limewater (calcium hydroxide, in combination with sodium bicarbonate and sodium carbonate form what is now Dakin’s solution a standard in topical burn care)13 vs a liniment of turpentine and followed the rabbits over time. Conclusions drawn from these experiments included that, “In more violent burns, attended with blisters and acute pain, a permanent relief is to be expected only from suppuration. This is promoted as in other cases of suppurative inflammation, not by acrid stimulants, not by snow and ice but by mild emollients and warm fomentations or poultices. … Perhaps no application is better than a liniment of limewater and oil.”3 Bigelow’s findings were not universally accepted. Members of different societies described remedies that they tried and worked. For example, Mr. Peppercorne described his use of lint soaked in a saturated solution of the carbonate of soda saying that it relieved pain possibly by neutralizing the acidulous quality of the perspiration.14 Smart found the oil and limewater hard to place on the head, face, and neck, so substituted with carbolic oil and a dusting of zinc, magnesia, and starch sifted when moisture appeared to create a kind of mask. He noted that this only caused trouble on the ear where abscesses were bothersome.11
Journal of Burn Care & Research January/February 2015
238 Hattery et al
The treatment of pain was rarely discussed in these historical works except with regard to which ointment seemed to sooth. Dupuytren believed, Brandy and opium are the remedies most to be relied on in the treatment of burns. “Brandy should be given in the form of milk-punch as furnishing with digestible food. Preparations of carbonate of ammonia and in doses of five grains made to an emulsion with gum and sugar may be given as often as every half an hour.”4 Smart would give the patients stimulants: sago and beef tea, anodynes of opium and chloral hydrate, chloroform to allay stomach irritation. After rallying, patients received beef tea, night and day limewater with milk to allay irritability of the stomach, and laxatives on the third day to relieve constipation. Animal food was then given such that the healing process would go on rapidly.11 There was no mention of patients requiring more nutrition secondary to their burns.
Surgical Treatment of Burns Modern burn treatment consists of the early tangential excision and grafting and the 1800s showed great advancements in the field of skin grafting.15 The father of plastic surgery, Sushruta, used skin grafts, as early as 600 BCE in India, to reconstruct noses lost to syphilis or punishment.16 Only rare anecdotal reports of skin transfers to noses were reported in Europe until the late 1700s. Skin grafts were further studied in 1804 by Guiseppe Baronio when he wrote Degli Innesti Animali where he first described experimental autologous skin transplant in a ram.17 Figure 1
shows his book’s illustration. Bunger further studied this in 1823, describing transplantation of the skin to human noses. M. Reverdin brought full thickness pinch grafts, to the world’s attention in 1869. He described removing skin from one arm and placing it in the granulating tissue of the other, thus creating small islands of skin on large burns with quick healing donor sites. Others repeated his work after hearing the account and obtained varied success.18 The 1870s had a broadening of skin graft techniques with Thiersh advocating for razor thin grafts and Ollier proposing a deeper thickness graft including part of the dermis.19 Split thickness grafts able to cover larger wounds consequently earned them the name Ollier-Thiersh grafts.20 Thiersh is also credited with increased aseptic technique in the fields of surgery.21 While these grafts were mostly done on chronic wounds and burns it laid the foundation for the future of burn care today. Reconstructive surgery for the cicatrix (scarring/ contracture) of burns was somewhat closer to what we have available today. As early as 1812, the release of burn contractures was alluded to in Dr. Bigelow’s work where, “it is necessary to divide the newly formed skin in different places, thus allowing it to expand.”3 In 1841 Dr. Mutter, a professor of surgery at Jefferson Medical college of Philadelphia, described burns of the neck constricting movement and the creating of a flap in order to correct the deformity. He was able to repeat the surgery on other patients.22 Figure 2 shows his illustrations over time of his first patient. The success of these skin grafts, flaps, and burn survival in general need to be taken into the context
Figure 1. From Degli Innesti Animali illustration of ram after skin grafting.17
Journal of Burn Care & Research Volume 36, Number 1
Hattery et al 239
Figure 2. Illustration from Mutter’s cases of deformity of burns relieved by operation.22
of the era. The first article on asepsis was published by Lister in 1867. “Antiseptics were used primarily to clean the environment, not surgical instruments, bandages, or wounds… at operation the surgeon might strop his knife on his boot or go so far as to hold blade between his teeth.”23 Ligation of bleeding vessels was a new technique to surgeons and cautery was fast falling out of favor for more modern tourniquets or suture techniques. Smart, in the Lancet, notes that he attempted to “maintain the highest possible degree of atmospheric purity, almost every known deodorant was used… sprinkled on floors from watering pots and on sheets hung round the offensive beds.”11 The idea of anesthesia, the use of inhaled gases, of ether and chloroform was another evolving area of medicine. It was not until the second half of the 19th century that surgical procedures regularly included the use of anesthesia. With orotracheal intubation having not been described until well after the civil war.24
Conclusion While there was many missteps in the evolution of burn care, there were also great achievements in the 1800s. The discoveries of the Marjolin’s and Curling’s ulcers showed improved understanding of the pathophysiology of burns. The idea of fluid resuscitation came quickly there after in 1905 with the first article by Haldor Sneve but the current recommendations were not brought about until 1968 and the Parkland Formula.25 Skin grafting techniques continued to improve but not until the late 1960s did they become significant in the acute treatment of burns. Inhalation injury had been noted to be a worse prognostic value but orotracheal intubation was still in its infancy. Ashhurst was correct in saying that burns required urgently immediate and judicious treatment; however, the 1800s proved that surgeons of the time tried very hard to correct their ignorance and incompetence on the subject.
References 1. Ashhurst J. On burns. Am J Med Sci 1862;XLIIL. 2. Naylor IL, Curtis B, Kirkpatrick JJ. Treatment of burns scars and contractures in the early seventeenth century; Wilhelm Fabry’s approach. Med History 1996;40:472–86. 3. Bigelow J. Nature in disease illustrated. Boston, Massachusetts: Ticknor and Fields; 1812. 4. Dupuytren M. Cases of burn. London Med Gazette 1833;11:742–3. 5. Lonsdale E. Burns by gunpowder. London Med Gazette 1833;81:696–7. 6. Erichsen J. On the pathology of burns. London Med Gazette 1843;XXXI:544. 7. Dupuytren B. On burns. London Med Gazette 1833;2. 8. Long J. On the post-mortem appearances found after urnbs. London Med Gazette 1840;25:743–50 9. Curling TB. On acute ulceration of the duodenum in cases of burn. [Manuscript of lecture read 28 June, 1842.] 1842:260. 10. Kingsley Opara ICO. Marjolin’s ulcers: a review. Niger Health J 2011;11:107–11. 11. Inspetor General Smart CBRN. On burns by gunpowder and scalds by steam. The Lancet 1976;1876:421. 12. Chesneau R, Kolesnik E. Conway’s all the world’s fighting ships 1860–1905. UK: Conway Maritime Press; 1979. 13. Lime water. Available from http://medical-dictionary.thefreedictionary.com/lime+water; accessed February 9, 2014. 14. Peppercorne F. Treatment of burns. London Med Gazette 1843–44;I. 15. Janžekovič Z. Once upon a time … how west discovered east. JPRAS 2008;61:240–4. 16. Bhishagratna KKL. The Sushruta Samhita—an English translation based on original Sanskrit texts. Calcutta, India: Kavirah Kunja Lal Bhishagratna; 1916. 17. Baronio G. Degli Innesti Animali. Milan: Dalla Stamperia e Fonderia Del Genio. 1804. 18. Power H. A biennial retrospect of medicine, surgery and their allied sciences. London: Dalla Stamperia e Fonderia Del Genio; 1870. p 49-61. 19. Ollier L. Greffes cutanees ou autoplastiques. Bull de L’Acad de med 1872;36:234. 20. Dailey G. Current medical thought. J National Med Assoc 1913;5:265. 21. Klasen H. Application of the principles of Thiersch in skin grafting, and further developments (1886–1900). History of free skin grafting. Berlin Heidelberg: Springer; 1981. p. 61–101. 22. Thos D, Mutter M. Cases of deformity from burns, relieved by operation. Philadelphia: Merrihew&Thompson; 1843. 23. Blaisdell FW. Medical advances during the Civil War. Arch Surg 1988;123:1045–50. 24. Robinson DH, Toledo AH. Historical development of modern anesthesia. J Invest Surg 2012;25:141–9. 25. Alvarado R, Chung KK, Cancio LC, Wolf SE. Burn resuscitation. Burns 2009;35:4–14.
