From mud baths to ‘No. 7 Paraffin’

Dr Barthe de Sandfort, a French rheumatologist, introduced the ‘ambrine’ wax treatment to the Academy of Medicine in Paris just before the outbreak of war.1–3 Formerly a Médecin-major in the French Navy, he suffered with severe rheumatism and retired to Dax, in Gascony, where his condition benefitted from local mud bath therapy. He developed the ambrine wax treatment, containing oils of amber mixed with paraffin, as a marketable synthetic pelotherapy that maintained a gentle heat flux into the skin.4 ,5 The medical profession was wary of de Sandfort's stated potential of ambrine6 ,7 in part due to his pecuniary interest in the mud baths and his guidebook to the spa treatments available there.8 However, following the outbreak of war, and with a lack of essential supplies at the Hôpital St. Nicolas at Issy-les-Moulineaux, he applied ambrine to a variety of wounds using an identical technique.9 His results were impressive and, rather by accident, Dr Barthe de Sandfort had identified a revolutionary dressing for the wounds of war.

In early 1916, this now evidence-based treatment was reported to the medical profession in the British Medical Journal10 and Lancet.11 It was promoted as an ideal burn dressing but the constituents were kept secret with a company in Paris controlling the sole distribution of the proprietary preparation.12 ,13 As the war continued, limited availability hindered the treatment of casualties. The Anglo-French Drug Company stated in the Lancet that preparations would soon be ‘…readily obtainable…’, albeit, one assumes, for an appropriate price.14 This lack of transparency infuriated allies in the USA with at least one author stating that such actions were ‘…in absolute contravention of American medical ethics….’15

It was at this time that Lt Col Hull identified the clinical need for an effective burn dressing that was easy to obtain, easy to apply and whose effects were reproducible throughout all allied field hospitals. The ambrine treatment evidently had merit and his research targeted paraffin wax compounds. He concluded that the results for ‘No. 7 Paraffin’ surpassed those of ambrine or other preparations.16 Hull's papers on paraffin treatment are some of the more robust articles published at the time and clearly describe his methodical approach and reasoned arguments for his decisive conclusion.

The thickness of the paraffin layer was crucial.

If it was applied too hot the layer was too thin and provided no support but if applied cooler the layer was too thick and failed to distribute evenly over the wound. Hull believed the efficacy of the treatment was due to the mechanical effect of the paraffin.

Crucially, Hull published the formulae for all his variants including ‘No. 7 Paraffin’. This open source approach was welcomed as much in the USA as the allied field hospitals. This heralded the paraffin wax era for burns treatment.

The author

Lieutenant Colonel Alfred John Hull RAMC published ‘The Paraffin Treatment of Burns’ in the Journal of the Royal Army Medical Corps in 1920, which follows up on his original article in the British Medical Journal in 1917.16 He was a surgeon at the Queen Alexandra Military Hospital and Lecturer in Surgical Pathology at the Royal Army Medical College before joining the British Expeditionary Force in France in 1914. Surgery in War,28 first published in 1916, and followed with a revised edition at the end of the war, was essential reading for every military surgeon during and after the war. He died in India from malaria in 1924.

This paper embraces the birth of reconstructive plastic surgery29 and the nascent understanding of burn wound pathophysiology and healing. It is a technical note but its true impact is easily lost on the casual reader unless appraised in the wider context of the treatment of burns before and during the War.