Open and closed treatment of burns

Abstract

Burns have certainly been dressed and probably also exposed for centuries. In 1832, in his Lefons Chirurgicales Orales, Baron Dupuytren stated 'Burns have always been subject to the most bizarre forms of empiric treatment'. Haldor Sneve of St Paul, Missouri, popularized the exposure of 'open air' treatment for burns in 1905 (Lowbury, 1978). Wallace (1949), in an article on the treatment of burns, A return to basic principles, proposed the 'exposure method' and wrote 'The control of burns is, without doubt, in just that confused state'. Was the increasing concern over the application of toxic substances to the burn wound a consideration? Dunbar in 1934, had shown how hazardous the development of Listerian principles in burns treatment had become. The overall mortality rate from burns treated by toxic substances had shown a pattern confirming the preference of simple cotton dressings. It was not until 1952 that Baar & Bull detected the presence of lactose in the body fluids of burned patients dusted with penicillin and lactose powder extolled by Wallace (1949) and questioned by Lowbury (1954). This illustrated the passage of substances through the burn wound into the body. Topical penicillin for burns has passed into history, but the absorption of toxic substances is still a problem. Deafness following the enthusiastic application of aminoglycoside powders to burned children, absorbed through eschar, has added to the black list of topical applications, showing that the barrier provided by an eschar is inefficient. Hippocrates was right with his 'First do no harm' principle. Controversy still continues regarding exposure. Can a wound to which an ointment or powder has been applied truly be exposed? Does not the preparation itself provide a dressing, thus negating the exposure principle? Current practice (Cason, 1981) suggests a diplomatic compromise; 'Burns may be treated with a mixture of exposure and dressings'. What are the basic principles underlying the exposure method? Wallace's (1949) three basic premises on conditions unsuitable to growth of microorganisms were: temperature below that of the body; lack of moisture; exposure to light. However true originally for bacteria, subsequent work suggests there is a