A New Technique in the Clinical Assessment of Bums*
By
MICHAEL N. TEMPEST
FROM THE PLASTIC SURGERY CENTRE, ST. LAWRENCE HOSPITAL, CHEPSTOW
iTCOMEsasa great relief these days to find that
with the passage of time the classification of
certain diseases becomes simpler rather than more
complex. Thus the modern classification of burns
into " partial skin loss " and " whole skin loss "
cuts clean through the more traditional and even
more confusing earlier descriptions of burn depth.
This new classification has the additional
advantage that it not only describes the lesion
accurately but also indicates the correct line of
treatment. Partial skin loss implies the presence
of sufficient epithelial cells in the dermis, hair
follicles and sweat glands to resurface the area,
whereas whole skin loss implies complete destruc-
tion of all epithelial elements so that healing can
only occur by migration from the periphery or
contracture of the bed of the wound.
Thus theoretically all partial thickness burns
should heal provided they are properly cared for,
whereas the ideal treatment for full thickness burns
should be excision and closure of the wound, either
by suture or skin graft. In practice, the value of
early excision of full thickness burns has been amply
confirmed by several workers but there are three
very significant limitations to this therapeutic
procedure:
1. Biological. The skin is the largest single organ
of the human body, and there would appear
to be limits to its destruction by burning or
excision beyond which survival of the patient
is impossible.
2. Technical. In the excision of major burns,
particularly in the very young and the aged,
there are very real problems of blood loss
including its estimation and replacement
before, during and after operation; dangers of
• Given at a meeting of the Association on 28th October 1960.
22
Downloaded from https://academic.oup.com/occmed/article/11/1/22/1366246 by guest on 06 September 2021
over-transfusion and citrate intoxication;
problems of anaesthesia; interference with
the normal body temperature-regulating
mechanisms; and also delayed metabolic
effects.
3. Diagnostic. This is often one of the greatest
limitations to the practice of early excision.
The Importance of Accurate Diagnosis
Although some burns may be well defined and of
a definite depth, the vast majority are mixed in
type, and in our enthusiasm to excise the full-
thickness burn we should avoid the unnecessary
excision of areas of partial skin loss. This is
especially important in the more extensive burns,
since we do not wish to increase the total area of
skin loss nor do we wish to sacrifice any skin that
may at a later date serve as a donor surface for skin
grafts.
Now there are many useful clinical methods for
assessing the type of a burn, such as its appearance,
its reaction to pin-prick, and not least important,
the taking of an accurate and detailed history of the
accident. But all these methods have definite
limitations and at best are only a very rough guide
to the extent and depth of skin damage. If we are to
advocate and justify surgical excision, especially
of the more extensive burns, the diagnosis should
be as " geographically " exact as possible so that
the surgeon can view the whole burn much as an
explorer reads the contours on his map or the
navigator the fathoms marked on his chart.
An early attempt to do this involved painting
the surface of experimental burns with a modified
van Gieson's stain, relying on the dye to distinguish
heat-altered from normal collagen (Patey & Scarff,
1944). Unfortunately surface staining gives little
information about the underlying dermal damage—

and it is this which really determines the natural
history of the burn.
Dingwall (1943) and other workers since then
have injected solutions of fluorescein intravenously
and then viewed the skin of the patient under an
ultra-violet light source in a darkened room. This
gives very valuable information indeed, but it is a
rather difficult method of investigation to introduce
into an operating theatre at the time of excision of a
major burn.
Radio-active tracer substances have also been
used in experimental animals and the surface of the
body then " scanned " with a counter so that a map
can be made of the burnt area. This is claimed to
be a very useful method, but the technical difficul-
ties are too great and the method is too slow to
make it very popular in a burns unit.
Intra-vital dyes have been used for many years in
the investigation of capillary permeability in
animals subjected to trauma and extremes of
temperature. Unfortunately most of these dyes are
extremely toxic to man. However, in his researches
into detachment of the retina in 1937 and 1939,
Professor Arnold Sorsby used two dyes, Kiton
Fast Green and Disulphine Blue, both in animals
and in man. Although he studied the pattern of
staining in the retina, he noted that the skin of his
patients became intensely stained shortly after the
intravenous injection of the dye, and that the dye
was excreted over the course of twenty-four hours
or so. In 1945 Gibson and Brown, working in the
M.R.C. Burns Unit in Glasgow, used Kiton Fast
Green in four burnt patients, but because of
unexplained vomiting did not repeat the experi-
ments on any other patients. In retrospect it seems
very probable that the vomiting they reported was
not due to the dye, but to the fact that the four
subjects were given the dye very shortly after
burning and may have vomited for quite different
reasons.
Since early 1955, we have injected both Disul-
phine Blue and Kiton Fast Green intravenously
on some 150 occasions in the investigation of burn
depth and in the investigation of tissue viability
following crush injuries and limb trauma. We have
proved that the technique is without danger and
without side effects. It enables one to observe the
state of the circulation in normal and damaged skin.
Not only does the technique delineate clearly
zones of undoubted whole skin loss and partial
skin loss, but the different patterns of skin staining
enable one to distinguish the varying gradations of
partial skin loss. For instance, fine closely packed
green " stippling" indicates superficial partial
thickness skin loss, whereas coarse, sparse
" stippling " indicates deep partial skin loss or a
23
A NEW TECHNtQUE IN THE CLINICAL ASSESSMENT OF BURNS
depth of destruction that is tantamount to full skin
loss.
The dye pictures must not be viewed in isolation,
but related to all the available data, the detailed
clinical history, the time since injury, the appear-
ance of the wound and the constantly changing
underlying pathological processes, particularly the
development of vascular stasis and thrombosis
leading to extensive tissue necrosis, sometimes
many days after the original injury.
The dye will not only delineate viable and non-
viable skin, but also indicate the viability of all
Downloaded from https://academic.oup.com/occmed/article/11/1/22/1366246 by guest on 06 September 2021
tissues which have an identifiable blood supply
such as muscle, fascia and bone. Other structures
normally considered avascular, such as tendon and
cartilage, will also show some degree of staining,
presumably by diffusion, provided they are still
viable. This pattern of staining in several tissues
enables one to excise adequately in depth not only
burns but other complicated wounds, particularly
the more severe crush and torsion-avulsion
injuries.
The technique can be applied to other branches
of general surgery, orthopaedic, ophthalmic and
neuro-surgery. The most interesting possibilities of
development would appear to lie in the fields of
bone and joint surgery, abdominal surgery,
experimental surgery and the investigation of
peripheral vascular disease.
Dosage
Aje Dose (ml.)
Disulphine Blue Kicon Fast Green
Children up to 3 years 5-10 2-3
10-15 3-5
3-10 years
10-20 years 20 5-10
20-40
Over 20 years , 10
Larger doses may be necessary in obese or very
muscular subjects.
Technical Data
Disulphine Blue is the monosodium salt of
anhydro—4:4' bisdiethylaminotri-phenylmethanol-
2": 4"-disulphonic acid, specially prepared by
the Research Division of I.C.I. (Pharmaceuticals)
Ltd., and supplied already sterilized as a 10%
TRANSACTIONS OF THE ASSOCIATION OF INDUSTRIAL MEDICAL OFFICERS
Figure 1. Burn of the forearm, the result of an
accident when setting offa rocket on Guy Fawkes'
day. The central whitish area was insensitive to
pin-prick and clinically a full-thickness burn.
The immediately adjacent red area showed very
poor sensation to pin-prick and the depth of skin
destruction was in doubt.
Figure 3. Extensive burns over both lower
limbs, especially the right, caused by ignition of
clothing in a boy aged 12. Although most of the
damage was of obvious full-thickness type, there
were several areas over the right thigh in which
some sensation to pin-prick could be elicited.
Downloaded from https://academic.oup.com/occmed/article/11/1/22/1366246 by guest on 06 September 2021
Figure 2. After an intravenous injection of
JO ml. Disulphine Blue both the central whitish
area and the immediately adjacent red areas
failed to show staining. By contrast, the
peripheral hyperaemic zone stained abnormally
deeply as compared with the staining showed by
the intact skin of the forearm. Experience has
shown that such unstained areas are typical of
full-thickness skin loss and this has been
confirmed by serial histological sections.
Figure 4. After an intravenous injection of 6 ml.
Kiton Fast Green it was noted that virtually all
the burnt skin, including those areas which
appeared to have some response to pin-prick, was
unstained by the dye. This " geographical" pic-
ture of the burn enabled one to excise with confi-
dence all the areas of full-thickness skin loss at
thefirstoperation.
 A NEW TECHNIQUE IN THE CLINICAL ASSESSMENT OF BURNS

Figure 5. Very extensive burns

in a little girl aged 6 as a result
of her clothes catching fire. The
burns also involved the greater
part of her back and her only
chance of survivalwas considered

Downloaded from https://academic.oup.com/occmed/article/11/1/22/1366246 by guest on 06 September 2021

to be early excision of the burn
and skin grafting, using a com-
bination of autogenous skin from
a few unburnt areas, and homo-
grafts taken from her parents.
In such an extensive lesion it is
obviously vitally important to
excise ONLY those areas of un-
doubted full-thickness skin loss,
since any area which will heal
spontaneously will not only
reduce the size of the defect to
be grafted but will also serve as
a potential donor site for auto-
genous skin grafts.

Figure 6. After the injection of Figure 7. Typical facial staining

6 ml. of Kiton Fast Green, the
areas of undoubtedfull-thickness
skin loss were clearly outlined
and this enabled an extremely
accurate surgical excision of the
burn to be carried out.
after an intravenous injection of
Kiton Fast Green. This boy is
recovering from the effects of a
general anaesthetic after excision
of a burn of the leg.

25
TRANSACTIONS OF THE ASSOCIATION OF INDUSTRIAL MEDICAL OFFICERS
solution in multi-dose glass containers. " Disul-
phine " (Sulfan) Blue is now supplied by Imperial
Chemical Industries Ltd., Pharmaceutical Division,
as a 6-2% solution in 10 ml. ampoules
(equivalent in tinctorial strength to the 10%
solution used in these investigations).
Kiton Fast Green is the sodium salt of tetra-
methyldiamino diphenyl-a-napthyl-carbinol
disulphonic acid, specially prepared by the
Research Division of Ciba Laboratories Ltd., and
supplied already sterilized as a 10% solution in
glass ampoules.
Administration
The dye is injected slowly either directly into a
suitable vein or indirectly into the tubing of an
intravenous infusion. Changes in the colour of the
skin are first seen within 60-90 seconds in those
areas with the most active blood supply, e.g. the
lips, face and ears. Complete body staining is
established in 3-5 minutes. Delay in the appear-
ance of skin staining may be seen in patients with a
poor peripheral circulation. No subjective effects
have been noted by the patients and there is no
interference with colour vision.
Excretion of the dye
The dyes are excreted very rapidly in infants and
young children, the skin becoming clear in 24 hours
26
or so. In healthy adults, the skin remains stained
for 48 hours or more with Disulphine Blue, but for
only 18-24 hours with Kiton Fast Green,
depending on the circulatory state, the renal
function and the fluid intake. The dye is excreted
mainly by the kidneys, but has been noted in saliva,
gastric secretions, bile, faeces and the tracheo-
bronchial secretions. It can also be found in
synovial fluid.
The dyes are not found in the cerebro-spinal
fluid since nerve tissue has the power of decolor-
izing the dyes rapidly by enzyme action (as noted
by Sorsby).
Downloaded from https://academic.oup.com/occmed/article/11/1/22/1366246 by guest on 06 September 2021
Although the dyes stain the plasma deeply, this
does not interfere in any way with the accuracy of
those laboratory examinations such as blood urea
and haemoglobin estimation which rely on
colorimetric methods.
References
DINGWALL, J. A. (1943), Ann. Surg., 117, 692.
GIBSON, T. AND BROWN, A. (1945), Spec. Rep. Ser. Med. Res.
Coun., London, No. 249.
PATEY, D. H. AND SCARFF, R. W. (1944), Brit. J. Surg., 32, 32.
SORSBY, A., ELKELES, A., GOODHARD, G. W. AND MORRIS,
I. B. (1937), ProcrR. Soc. Med., 30, 2171.
SORSBY, A. (1939), Brit. J. Ophthal., 23, 20.