Antecedents from the history of burn therapy:

      

 

Burn injuries have existed since the invention of the fire. Their first written recording perhaps can be found in the Ebers papyrus (1500 B.C.), which recommends for treatment the mixture of cattle dung and black mud. In the following millennia almost every famous physician recommended some kind of method for the healing of burn injuries, as Dupuytren, the famous French surgeon wrote at the beginning of the 19th century: “burns had been the object of one of the most bizarre treatment methods”. The first book about burns was written by the German Fabricius Hildanus in 1607 and he was the first one who also prepared a three-grade classification for the assessment of the severity of burns. Reports were published one after the other about open and closed treatment, cooling, classification of severity and observations about pathology. Treatment by operation has been the topic of discussions only in the last 130 years after the working out of the skin transplantation procedures, although in the beginning these were used only for late skin grafts and for the scar correction after conservatively treated and healed burns, respectively. The first attempts for the excision of burn injuries took place in the beginning of the 20th century. Although patients with burn injuries were also treated in surgery departments, yet primarily this was the “illness of the skin”, therefore the treatment occurred mainly in departments of dermatology. The breakthrough was brought about by the rapid progress in the knowledge of pathology, learning about fluid and electrolyte balance and the experience gained during World War II. The specialists had realized that the treatment of burn injuries requires special expertise and primarily the point of view of a surgeon, thus they established independent departments one after the other for the treatment of patients who had suffered burn injuries.

 

 

Burn treatment in Hungary

 

The first written record in the Hungarian professional literature is the article of Károly Weszelowszky in volume 2 of Orvosi Hetilap [Medical Weekly], in 1858, in which he recommends “argentum nitricum = lapis lazuli” in “oil ( Rp. Arg.nitr.fusi partem 1.s.aquae d.s.q.et adde Olei lini partes 8-3)”, for use twice daily, for the treatment of “a 2nd (dermatitis combustionis bullosa) and 3rd (derm.comb.escharotica) degree burn”. In the course of the  following 70-80 years a report about the treatment of burn injuries is rarely published in Hungarian medical literature, they are primarily the abstracts of foreign articles and even more rarely they are the case studies about a peculiar burn injury or the trying of a treatment method on a small number of patients.

The first summarizing report was written by László Czirer in the 23rd issue of the year 1937 of Orvosi Hetilap mentioning only conservative treatment methods. In the same year Endre Hedri made a presentation at the XXIIIth general meeting of the Association of Hungarian Surgeons about their 552 patients treated in the course of  8 years, not saying a word about operational treatment methods, primarily preferring the burn treatment by tannic acid, which “had become the vogue” at that time. 12 years later in 1949 the first articles of the young surgeon, György Frank, were published about the treatment of burn. In October 1951 first the dermatologist and then the surgeon specialist team held a meeting about burn injuries. The summary abstract of Béla Egyed was commented on by several people (Orvosi Hetilap, 1952, vol. 93, pp. 173-186.). Endre Fejér should be emphasized among these, who presented an account about the large burn patient material of the dermatology department of István Hospital (10% of all patients had burn injuries) as well as Miklós Érczy, who stressed that the misconception should be rebutted that the clearing up or formation of epidermis should be awaited before performing plastic surgery. He recommended early plastic surgery (on days 10-20 !!!). The two specialist groups made the proposal to the Ministry of Health that also in Hungary the need exists for having an independent burn department. The Ministry accepted this proposal and on January 1, 1953 the first burn department was established in the Hospital of Kun-utca in Budapest and György Frank (1911-1959), who was the 42 years old at the time, was appointed the head of the department.

György Frank started to deal with the problem of burn injuries at the recommendation of professor Hedri, the pioneer of Hungarian burn treatment. His first articles were published in this set of themes in 1949. He had an extraordinarily wide range of reading and although his career took another course (e.g. he was the director of the National Blood Bank Organization), when he was appointed the chief physician of the first Hungarian burn department starting from January 1, 1953, he set forth organizing the department knowing all the novelties of burn treatment at that time. Patient care started on March 7, 1953 with two subordinate physicians, a small team of nurses and rather inadequate equipment on the first floor of an almost 100-year old building. Yet the treatment methods were extraordinarily modern, he introduced the application of homograft as well as several new modes of bandaging technique. He developed operation tactics, which is still acceptable in terms of several of its elements when looking at it today. He was far ahead of his time by operations performed early in patients with extensive burn injuries and by the hibernation procedure developed by him and he won with his report about this procedure the 2nd prize at the competition of the professional journal entitled Plastic and Reconstructive Surgery. His lifework was summarized in a book (published posthumously because of his early death) in 1961. In this book he rendered an account of 1977 patients treated between 1953 and 1959, among whom 505 operations were performed in 381 patients (19,2%), which was an extremely high rate a quarter of a century ago. It is characteristic of his knowledge of the professional literature that he listed the references to the literature on 26 pages at the end of the book. Sepsis suffered during an operation as a consequence of an injury caused his death on December 9, 1959.

      

Burn centers in Hungary

      

Independent burn departments

      

The first burn department was established in Budapest, in the Hospital of Kun-utca with 41 beds. Its first chief physician was György Frank (1953-1959), he was followed by Péter Máday (1960-1969), then the disciple of Dr. Frank, András Hoffer (1970-1974). László Ménesi (1974-1997) was appointed to head the department in 1974. Under his leadership the department was transformed to become a burn and plastic surgery department with a large amount of activity, with an independent intensive care unit and the early operations became an everyday occurrence. He acquired singular practice in this country in his most favorite specialty, the treatment of the burned hand. A stabile physician group was formed at the department, which performed pioneering activities in several areas in this country, for example in the area of musculo- and fasciocutaneous lobes applied in reconstructive surgery, in which the roles of László Ménesi and Éva Csorba have been decisive. In 1998 Éva Csorba took over the management of the department. After 47 years on January 24, 2000 the department moved to the renovated building “B” of Szent István Hospital expressly reconstructed in accordance with the requirements of the department, where it can receive the patients on three levels on 31 beds (4 intensive care, 19 burn related and 8 plastic surgery) in 4 operating-rooms (2 septic, 1 plastic surgery and 1 outpatient) this opened a new chapter in the history of the first and biggest Hungarian burn department. The intensive care unit outfitted with high quality equipment can receive the severely injured patients with burn injuries (arriving from Budapest and a number of cities of the country) on 4 beds placed in separated boxes. In the intensive care unit 4 respirators and 2 fluidization beds are available (which is supplemented by a third one placed in the unit), each box has its own bathing panel and the possibility of cross contamination has been reduced to the minimum. As a result of the circumstances not comparable to those of Kun-utca, several changes in the treatment regimen became possible (e.g. the elimination of prevention by antibiotics). In the beginning of 2001 the hospital started a disciplinary process against the head and assistant head of the department and then it dismissed them. The labor law related as well as pro and con compensation processes started after this have not been fully concluded even by now. Gábor Mészáros was entrusted with managing the department. Under his leadership at present 7 plastic surgery (burn injury) surgeon specialists are working, chief physician György Sáfrány, György Falus assistant professor, Erika Honti assistant professor, Zsolt Révész assistant professor, Attila Domonkos junior physician, János Gyetván junior physician and Eltahir Yassir specialist and they are supplemented by two anesthesiologists (who have been working at the unit for a decade, but who do not belong to it as far as their status is concerned) Ágnes Csatáry and Judit Erdős assistant professors (apropos the latter also has plastic surgery specialist certification). The referrals to the department have been unchanged (in 2002 there were 839 hospital admissions of which 338 were burn injuries and almost 100 patients were treated at the ICU, the number of operations was 1531 of which 474 involved patients with burn injuries). The treatment strategy has not changed, a series of operations started early and continued for several days and early respiratory therapy (already on the basis of anamnestic data) in the case of burn injury of the respiratory tract. Microsurgery activity has also been taking place at the department since 2000 (not only in cases of breast reconstruction, but also for the correction of abdominal injuries). In 2001 another important and sad event occurred: on November 11 István Szalai passed away, who had been an employee of the department since 1969 and on three occasions the acting head of the department for several months. Only those who knew him know what kind of a unifying linchpin he had been, an embodiment of those from „Kun-utca”.

The following burn department opened in Budapest in 1961 in the Central Army Hospital under the leadership of János Novák (1961- 1989). His work is outstanding in the treatment of burns in Hungary. The theme of his first scientific degree and Ph.D. dissertation also featured burn injuries. He is the author of an extraordinarily large number of communications and he wrote notes and a book as well as chapters of a textbook about the treatment of burn injuries. His teaching and research work is equally significant. He had a fundamental role with professor János Zoltán in the introduction of the independent plastic surgeon and burn surgeon specialist examination. He initiated the joining of hands of domestic specialists and this is how the Burn Section of the Hungarian Society for Traumatology came into being in 1974 and he was its first chairman. András Szűcs (1989- ) is his successor in the department, who presently leads the department which experiences more difficult circumstances because of the reduction of the number of beds.

The next independent department opened in the Army Hospital in Pécs in 1969. Its first chief physician was Ottó Lux (1969- ), then Zoltán Török ( ) took over the leadership and has been leading the department until he retired in 2002. His successor is Tibor Baranyi. A great deal of experience has been gained in the treatment of large numbers of the injured sustaining their injuries in mining catastrophes and it is not by accident that it was this department which particularly urged the drafting of plans to deal with catastrophes and the formation of experienced teams. Zoltán Török was the first chairman of the Hungarian Burn Association which became independent.

The fourth independent department opened in Győr in 1984 whose first chief physician was János Kósa (1984-1993), who organized the new department with modern architectural endowment. Equipped with experience acquired in the National Traumatological Institute and in the burn department at Kun-utca, quickly developing it to a level of excellence. It was at his initiative that the tissue bank was created in Győr, which supplies all the burn departments of the country with pigskin xenograft and hopefully with keratinocyte culture in the near future. Since 1994 Péter Jakabos has been leading the department by the same high standards introduced by his predecessor.

      

 

Burn sections/departments functioning

as part of larger organizational units

      

It was in Miskolc where organized burn injury care first came into being in the eastern part of the country – in accordance with the requirements of the industrial region – in the section of the department of traumatology of the Borsod-Abaúj-Zemplén county (Szentpéteri Kapui) Hospital. At the beginning of the 1960s the first chief physician was András Hoffer, who led the department until 1970 in accordance with the modern view learned from György Frank, when he returned to Budapest to the Hospital of Kun-utca. He was the inventor and initiator of the Burn Club, which made the meetings of domestic specialists regular. His successor was Tibor Papp. The present director of the section is Sarolta Tarr. The department carries out the care of adult injury patients, while children with injuries are cared for at the department of child surgery under the directorship of Rózsa Papp. The Burn Section of Child Surgery was renamed to: Child Surgery Regional Burn Center, Miskolc. No financial support was given with this new name, therefore the organizational form could not be changed. There was a minimal enlargement at the expense of the Department of Child Surgery. The reconstruction of a new ward was concluded, in which the possibility exists for putting in a fluid bed. Further reconstruction of the ward is among future plans as well as the acquisition of a bathing contrivance/fürdető kocsi, which so far could not be realized because of lack of funds.

---- Camillo Bertényi started to work at the Dermatology Clinic of Szeged on January 1, 1963, who began the surgical care of patients with burn injuries and skin tumors under special circumstances in 1965 on 10 beds, he was the initiator of the Dermatosurgical Section of the MDT (Hungarian Dermatological Society) and it was in his department that the first successful  epidermis culture transplant took place in this country. His successor and the present director of the department is: Klára Kapitány associate professor. The former Burn-Plastic Surgery, recently Dermatosurgical Department functions with 20 beds, of which 5 beds serve the tasks of burn injuries. In case of need the area can expand, 1 intensive care room is in operation, which is suitable for ensuring intensive care circumstances with regard to the equipment, but unfortunately from the financing point of view of it cannot be considered an intensive care bed. They have at disposal two surgeon specialists, 4 female operating-room assistants, 2 operating-room assistants, 7 specialist nurses, 1 specialist assistant, one intensive care anesthesiologist and one anesthesiologist specialist assistant (the latter two are on the status of the Central I.C.U.).

At the medical faculty of the University of Arts and Sciences of Debrecen established in 1918 a Clinic of Dermatology and Venereal Diseases was functioning already in the academic year of 1921/22 under the leadership of professor Ede Neuber. During this early age no data are available about the treatment of patients with burn injuries, but according to contemporary documents during the World War II the care of patients with burn injuries took place and since then has been taking place at the Clinic of Dermatology. The place of severely burned patients was formed in the middle of the large male and female wards in the northern wing of the building with the consideration that the other patients could also cooperate in caring for the helpless patients. The patients who had suffered lesser burn injuries were placed in a scattered fashion among the patients with dermatological conditions.

The director of the Dermatology Clinic of Debrecen from 1949 to 1974 was professor Dr. Lajos Szodoray, who applied the wet treatment which is widely accepted today also in the treatment of burn patients which was at that time it was contrary to the general concept of “wound healing under the dry scab”. Treatment with ointment containing chlorophyll is associated with his name. In1970 local treatment was performed in patients with burn injuries with Primycin dissolved in water (today: Ebrimycin), the first Hungarian antibiotic drug produced by István Vályi-Nagy, professor of pharmacology in Debrecen. The formation of the burn department, i.e., the separation of patients with burn injuries from the dermatological patients was realized under the leadership of professor Endre Nagy, who directed the clinic from 1974 until 1992. The director of the burn department was first Gyula Alföldy lecturer (until 1982) and then András Tamás assistant professor (until 1995). In 1982 the burn department moved to the reconstructed eastern wing of the clinic and it was enlarged by a new operation theatre. The director of the Clinic of Dermatology of DEOEC [University of Debrecen Center of Medicine and Health Sciences] (formerly DOTE [Medical School of Debrecen]) is professor János Hunyadi and the burn and dermatological surgery department is directed by István Juhász (med.habil), who is associate professor with university professor's qualification. Another 3 physicians work at 22 beds (of which 4 are intensive care and 5 are children’s beds):

Irén Erdei, assistant professor, dermatologist and intensive care-anesthesiologist specialist, Zoltán Péter lecturer, general surgeon–plastic surgeon, Éva Szabó dermatology specialist, surgery specialist candidate and furthermore the team is complemented by a dermatology specialist candidate in rotation. The burn team directed by István Juhász cares for burn injury patients in accordance with modern treatment principles and conducts research, in which at present they have at their disposal unique opportunities in this country.

The care for injured children in this country in most places is separated from that of the adults. In this activity the role of József Baksa is fundamental. He undertook the responsibility for the treatment of children with burn injuries by forming separate burn sections within the children’s surgery departments at each workplace of his (first in Miskolc, then in Budapest Children’s Hospital of Madarász utca, the children’s surgery department  of the Hospital of Southern Pest and finally at the children’s surgery department of  Szent János Hospital) for. Already in 1967 he made an account of a patient material comprising 10 years.

In his communications early operations, new treatment procedures and the methods of treating scars are equally featured and he had a pioneering role, e.g., in the introduction of the possibilities of treating scars with compression bandages in Hungary. He was the secretary of the Burn Section of the Hungarian Society for Traumatology since its foundation in 1974 and then that of its legal successor, the Hungarian Burn Association until 2000. He has not been in our midst since 2001.

The Child Surgery Department of Szent János Hospital has been directed by Dr. Attila Pelényi where the burn section continues to care for child patients with burn injuries of Budapest under the directorship of Dr. Sándor Győri.

 

In the course of 2002 the Bethesda Child Hospital of the Reformed Church was enlarged by a section capable of caring for children with burn injuries and in this way the Bethesda Hospital National Center and Intensive Care Department Treating Children with Burn Injuries was established. Its head became Dr. Éva Csorba whose colleague is Dr. Ruzsena Bene both of whom have 20 years of experience in caring for patients with burn injuries. A section bathing burn wounds belongs to the intensive care unit and to the department, where the daily bandaging is carried out under narcosis, thus the children spend the period of recuperation without pain. The organization and establishment of the department was the joint work of the Ministry of Health and of the Hungarian Reformed Church.

 

The present situation of the burn centers (2004) (click here!)

 

The formation of the Hungarian Burn Association and its legal predecessor

      

At the initiative of János Novák in 1974 the Burn Section of the Hungarian Society for Traumatology was formed. After 18 years of operation the general assembly of the Section voted to be transformed into an independent society, thus in 1992 the Hungarian Burn Association (MÉE=HBA) was formed, which at the present time has about 150 members. The Section and then the Association has always laid a great deal of emphasis on the desire that – expressing the teamwork character of caring for patients with burn injuries – a regular nurses’ forum should also be presented at conferences and/or the Section and the legal successor Association should also accept into the ranks of its members not only the physicians dealing with patients with burn injuries, but also the specialist workers (female and male operating-room assistants, nurses and physical therapists)  i.e., everybody, who cares for patients with burn injuries. In 2000 the MÉE=HBA was admitted to MOTESZ. The association is also a member of EBA (European Burn Association) and of the Mediterranean Burns Club.