The present status of research in burn toxins.

Modern intensive care combined with current improvements in the specific, systemic and local therapy of burns has delayed the mortal effects of severe burns. Nor has there been any significant improvement in this mortality during the last decade. The occurrence of uncontrollable infection and sepsis due to gram-negative bacteria or fungi as the basic cause of death was not a satisfactory explanation. So, progress should only be expected from a new concept in burn treatment. This new concept should be to view the burn disease as being caused by toxic factors induced by thermal injury to the skin. Electron-microscope studies in mice and rats have revealed similar mitochondrial alterations in hepatocytes after either a sublethal controlled burn injury or an intraperitoneal application of an equivalent dose, of a cutaneous burn toxin. The intraperitoneal injection of different amounts of the burn toxin indicated, that the extent of the mitochondrial changes correlated directly with the dose of toxin. Investigations of liver metabolism suggested an inhibition of the oxygenation chain. The incubation of isolated liver cells together with the burn toxin demonstrated by scanning electron microscopy a direct cytotoxic effect of the burn toxin. In animal tests the pathogenic effect of the burn toxin could be prevented by treatment with an antitoxic IgG generated in sheep. The fatal sepsis of severely burned patients is the consequence of a decreased host defence against infections, which is caused by a primary and general toxic alteration of the whole organism. One important aspect of treatment should therefore be the elimination of burn toxins. To achieve this management should include primary excision of the burns, local application of nonabsorbable protein-complex-binding substances and specific passive immunotherapy with an antitoxic IgG.

Trauma systems in Europe.

For prehospital care, Switzerland developed the first helicopter air rescue system but it has been surpassed by the Federal Republic of Germany, where a coordinated rescue system of physician-equipped air and terrestrial transport has been developed. With regard to hospital care of trauma victims, three systems have evolved. In Austria and the Federal Republic of Germany, the "general surgeon-traumatologist" is in charge. In these countries, the Workmen's Compensation Board restricts treatment privileges to trauma surgeons. In Switzerland and Holland, general surgeons in regional hospitals and to some extent also in university centers have largely remained responsible for trauma, including fractures. In Great Britain, as in other major European countries like France, Italy, and Spain, trauma of the locomotor system is the domain of orthopedic surgeons, with multiple trauma and body cavities remaining the responsibility of general surgeons. Overall, there is a general tendency to create integrated trauma care systems within large hospital settings. Although an experienced general surgeon can function as the leader of the trauma team, such implementation has, for the most part, not occurred.

Sphincter-splitting approach to the rectum.

This is a brief report of experience gained on our service with the sphincter-splitting approach to the rectum. The main indications for the approach are emphasized. Sphincter splitting is a new way to resolve surgical problems that have been difficult to solve before. It should be offered to suitable patients who otherwise would have to undergo more extensive operations that carry with them more inherent liabilities.

Respiratory assistance on surgical wards with continuous positive airway pressure (Turbo-PEEP-Weaner).

Based on our own experience, we introduce a new continuous positive airway pressure device. The patient can breathe continuously positive airway pressure through a tight face mask, and thus the postoperative reduction in functional residual capacity is counteracted. This is shown by the well-documented clinical course of a 62 year old man who had respiratory insufficiency after proximal selective vagotomy.

Comparison between glucose and a combination of glucose, fructose, and xylitol as carbohydrates for total parenteral nutrition of surgical intensive care patients.

The effects of four day periods of infusions of 600 gm/24 hours glucose and 600 gm/24 hours of a combination of glucose, fructose, and xylitol were compared. This study was performed during total parenteral nutrition of twelve postoperative patients with major complications. The mean plasma glucose level was significantly lower during the infusion of the combination of sugars (154.2+/-19.5 mg/100 ml versus 193.9+/-15.0 mg/100 ml[p is less than 0.005). Furthermore, the required dosage of exogenous insulin was significantly lower (18.9+/-12.3 units/day versus 43.7+/-19.7 units/day [p is less than 0.01). Mean renal carbohydrate losses were 0.85 per cent during glucose infusion and 1.7 per cent during infusion of the combination. The influence of both infusion regimes on values for pH, base excess, lactate, pyruvate, free fatty acids, insulin, sodium, potassium, chloride, magnesium, phosphorus, bilirubin, alkaline phosphatase, SGOT, and SGPT 0.85 has been investigated. No clinical side effects were observed. It is concluded that the administration of the investigated combination of glucose, fructose, and xylitol is justified in patients in whom hyperglycemia during infusion of glucose alone is difficult to control with insulin.

Intercondylar fractures of the humerus. An operative approach.

In this paper we review a series of thirty-four intercondylar fractures of the distal end of the humerus that were treated by open reduction over a ten-year period. The fracture patterns were classified according to the system of Müller et al. and a strict rating scale incorporating subjective data, objective motion, and the functional status of the involved elbow was used for the results. At a mean follow-up of 5.8 years, thirteen results were rated as excellent; fourteen, as good; four, as fair; and three, as poor. Complications included postoperative neuritis in five patients; three non-unions; and refracture, heterotopic bone, and deep sepsis in one patient each.

Anatomy of the pelvic floor for translevatoric-transsphincteric operations.

The parasacral transsphincteric-translevatoric approach has proved of great interest in surgery of the lower rectum and urogenital organs. Due to this experience, anatomic specimens of the pelvic floor and pelvic organs were prepared in order to perfect the operative technique. The anatomic specimens show the pelvic floor and sphincter muscles and the blood supply by the pudendal vessels and nerve, as well as the topography of pelvic organs and fascias from the view of a surgeon performing parasacral surgery. The clinical experience with 118 cases of parasacral translevatoric-transsphincteric interventions at the Departments of Surgery of the University Hospital, Basel, and the Canton Hospital, Luzern, Switzerland, is presented. The results were mainly good. The operation technique is illustrated with selected cases of rectum resection, procedures for treatment of urethrorectal fistulas, reconstruction of pelvic floor for malformations, and reconstruction of injured urethra.

The floating shoulder: ipsilateral clavicle and scapular neck fractures.

In ipsilateral mid-clavicular and scapular-neck fractures, the mechanical stability of the suspensory structures is disrupted and muscle forces and the weight of the arm pull the glenoid fragment distally and anteromedially. To prevent late deformity we recommend internal fixation of the fractured clavicle by a plate and screws. We treated seven patients with this unusual injury; all achieved an excellent functional result without deformity.

Influence of burn-induced lipid-protein complex on IL1 secretion by PBMC in vitro.

The lipid-protein complex (LPC) formed by thermal injury to skin, which has been shown to have a toxic effect on mice, and which suppresses the immune response, was tested for its specific influence on monocytes. Growth of bacterial endotoxin-stimulated peripheral blood mononuclear cells (PBMC) was inhibited in the presence of LPC, however, the inhibition was less at the time of the optimal rate of cell proliferation. Inhibition was proportional to LPC concentration. ConA-stimulated PBMC were also inhibited by LPC in a dose-related manner. PBMC, in the presence of LPC, secreted interleukin 1 (IL1) at an increasing rate as LPC concentration rose from 5 to 40 micrograms/ml, and the levels of IL1 which could be induced by endotoxin were increasingly amplified in the presence of LPC. In comparison to LPC, the native tissue proteins which were isolated from unburned skin by the same techniques which produced LPC from burned skin, were tested for their effect on PBMC. Native proteins had no effect on IL1 secretion, whether on background or endotoxin-stimulated levels. Thus, the thermally induced change in skin proteins has a specific effect on monocyte IL1 secretion which is not matched by the native proteins, indicating that burn injury to skin specifically affects the lymphokine cascade and consequent immune function.

Skin toxicity induced by wet heat.

Pieces of human skin from the skin bank were heated in an autoclave for 1 or 5 min at temperatures 80, 90, 100, 110 and 135 degrees C. The pieces were then homogenized and the homogenates were injected intraperitoneally into groups of mice. The amount injected was either a quantity equivalent to 50 or 75% of the mouse body surface area. Fourteen separate experiments were carried out, each one with a variety of temperatures. Mortality in the groups of mice was recorded by the 8th day. Control mice received homogenates of skin heated to no more that 38 degrees C and out of a total of 104 control mice there were only 4 deaths. In contrast homogenates of skin heated to 135 degrees C killed from 80 to 100% of the mice in different groups, averaging 92%. Skin heated to 110 degrees C killed from 33 to 90% of the mice in different groups, averaging 63%. Skin heated to 100 degrees C killed from 0 to 80% of the mice in different groups, averaging 33%. Temperatures of 80 and 90 degrees C killed no more than 10% of the mice in any group, averaging less than 3%. One minute of heating seemed to be sufficient to induce the toxic effect in the skin. These findings indicated that wet heat application to skin was capable of inducing toxicity in a fashion similar to that demonstrated many years ago with hotter dry temperatures applied to skin for 15s. That application was shown to induce polymerization of skin cell membrane lipid proteins rendering them toxic. In this study, increasing toxicity appeared similarly to depend on the quantity of wet heat input as illustrated by the range of increasing temperatures. The relatively lower temperatures of scalding versus flame burns can accomplish similar dangerous effects; it is simply a quantitative matter of heat input.

Plasma levels of cutaneous burn toxin and lipid peroxides in thermal injury.

Lipid peroxides, formed as a consequence of oxygen free radical formation, are responsible for tissue damage in a great variety of pathological conditions including thermal injury. 'Cutaneous burn toxin', formed by application of heat to skin, is thought to be specific to the burn injury. It causes dose-dependent damage to mitochondrial and red cell membranes, and dose-dependent inhibition of interleukin-2-dependent growth of lymphocytes. The possibility that the toxicity of 'cutaneous burn toxin', a lipid-protein, is exerted through lipid peroxides, was examined by measuring the levels of both agents in plasmas of eight burn patients during the first week after their injury. It was observed that plasma lipid peroxides did not appear in parallel with absorption into the circulation of 'cutaneous burn toxin'. Lipid peroxide levels equally common to very low and very high burn toxin levels, were recorded. The pair of agents correlated negatively (r = -0.26) at a significance of only 0.1. In addition, isolated purified 'cutaneous burn toxin' contained no measurable lipid peroxide. No relationship was therefore demonstrated between plasma levels of 'cutaneous burn toxin' and lipid peroxides.

Survival in major burn injuries treated by one bathing in cerium nitrate.

Sixty-four patients aged 16-74 years with total body surface area burns (TBSA) ranging from 30 to 90 per cent, were given one bathing in 0.04 M cerium nitrate within 4 h of admission to hospital. Of 21 patients aged 16-30 years, one died (aged 28 with 90 per cent TBSA), and of those aged 31-74 years, two died, one (aged 50 years with 55 per cent TBSA) had multiple internal injuries, the other (aged 51 years with 55 per cent TBSA) had a pulmonary embolism at day 19. Two risk scores, developed from data on 11,200 burn patients treated by standard methods (Roi et al. 1983), were applied to the analysis of risk for 59 patients for whom both total burn surface (TB) and full thickness (FT) areas had been recorded. About 20 patients bore risk of 0.8 or greater on the FT scale and 1.0 on the TB scale, yet instead of 80 per cent deaths among these, only two died. No FT assessment had been made on the multiple injury death whose TB risk score was 0.66. Such survival results in high-risk patients should encourage the use of cerium nitrate for treating serious burn injury.

Bilateral fractures of the lower leg due to skiing accidents.

The results of treatment in 13 bilateral lower leg fractures due to skiing accidents are presented. All patients were treated by internal fixation according to the principles of the Swiss Association for the Study of Internal Fixation. The patients on the average were mobilized after nine days, discharged after 24 days, started to use walking braces after 17 days, and undertook partial weight bearing 10 weeks and full weight bearing 14 weeks after the accident.

Unicondylar fractures of the distal humerus: an operative approach.

This paper retrospectively reviews a series of 22 unicondylar fractures of the distal end of the humerus that were treated by open reduction and internal fixation over a 10 year period. The fracture patterns were classified according to the system of Müller et al. A strict rating scale was developed that incorporated subjective data, objective elbow motion, and the functional status of the involved elbow. At an average follow-up of 5.9 years (range 2.3 to 12.3 years), 12 elbows were rated as excellent, 6 as good, and 4 as fair. Complications included extensive posttraumatic arthritis in four patients, a nonunion in one, and a transient radial nerve palsy in one.

General surgery and trauma.

While some degree of specialization is essential in surgery there remains a place for the general surgeon. The tendency to regard surgical intensive care as a specialty should be resisted. Similarly the surgery of trauma should remain in the field of the general surgeon in full co-operation with the orthopaedic surgeon and, in special circumstances, the neurosurgeon.

Burn sepsis and burn toxin.

The salient steps of a 20-year programme of research into the nature of burn disease are described. By burn disease we mean the late mortality and morbidity following burns. We have isolated a burn toxin which is derived from a thermal polymerization of cell membrane lipoproteins within the dermis and have studied its influence on the effects of sepsis. We have also used it in the development of active and passive immunization therapy of severe burns.

[Femoral neck fractures: conservative or operative therapy in view of therapeutic results and rehabilitation]. / Die Schenkelhalsabduktionsfraktur: konservative oder operative Behandlung im Hinblick auf behandlungsergebnis und Rehabilitation.

The analysis of late results of 75 consecutive cases of abduction fractures of the femoral neck gave the following results: One third (24/75) of the patients must be operated because of a secondary dislocation. This secondary dislocation cannot be predicted. All the patients successfully treated conservatively can walk like before the accident. This confirms our therapeutic concept for abduction fractures of the femoral neck: Primary conservative treatment with immediate mobilization and weight bearing. Secondary operation for the cases with varus dislocation (one third).

Neuromuscular tissue defects and antropyloric dysfunction in peptic ulcer.

Pathomorphology of antropyloric wall in peptic ulcer disease includes: 1. Asymmetrical hypertrophy of the muscle, 2. Reversible changes and irreversible damage of a part of muscle cells and ganglia, 3. Tissue infiltration: Eosinophils and mast cells, 4. Scar formation (fibrosis) in the muscle and submucosa, 5. Edema formation of the submucosa. This is not found in controls but constant in peptic ulcer disease. Changes do not depend upon the ulcer site, size and number and are common in the antropyloric wall of all patients with peptic ulcer but most pronounced in gastric ulcer.

Gastric hypermotility and antropyloric dysfunction in gastric ulcer patients.

Impaired gastric emptying in gastric ulcer patients has been explained by gastric hypomotility. Amplitude and duration of the contraction and integrated motor response to an electrical vagal stimulus, however, have been found to be significantly greater in 21 GU patients than in 25 DU and 6 combined ulcer patients. This shows hypermotility of the gastric muscle in GU patients. Delayed gastric emptying in GU disease, therefore, seems to result rather from antropyloric motor dysfunction than from gastric hypotony. Abnormal motility associated with duodeno-gastric reflux appears to be a key feature in the pathogenesis of gastric ulcer.

The different outcome of duodenal and pyloric channel ulcers after proximal gastric vagotomy. Clinical and morphological results.

Pyloric channel ulcers have a significantly higher recurrence rate than duodenal ulcers after proximal gastric vagotomy (PGV) without drainage. The failure of PGV cannot be explained by the pre- and postoperative secretory pattern of pyloric (PU) and prepyloric (PPU) ulcers. The morphological assessment of the pyloric and antral wall in DU, PU and PPU shows a significant thickening of the muscular layer in PU and PPU compared with DU. Histologically there is a muscular hypertrophy combined with muscular and ganglionic cell damage and fibrosis. The observed antropyloric dystrophy might be one factor for explaining the failure of PGV alone in pyloric channel ulcers. Addition of a drainage procedure for PU or even of a limited antrectomy for PPU might improve the postoperative results and must be discussed when planning surgical treatment of pyloric channel ulcers which seem to characterise as a distinct entity of peptic ulcer disease.