Editing Cocoanut Grove fire (section)

==Medical treatment==
[[Massachusetts General Hospital]] (MGH) and [[Boston Medical Center|Boston City Hospital]] (BCH) received the majority (83%) of the victims from the fire;<ref name = "Lyons">Louis M. Lyons, "Boston Doctors Tell Lessons Learned from Grove Fire," ''Boston Globe,'' Tuesday, Dec. 14, 1942, p. 1.</ref> other Boston area hospitals received a total of about thirty patients: [[Peter Bent Brigham Hospital]], [[Beth Israel Deaconess Medical Center|Beth Israel Hospital]], [[Cambridge Hospital (Massachusetts)|Cambridge City Hospital]], Kenmore Hospital, [[Faulkner Hospital]], [[St. Elizabeth's Medical Center (Boston)|St. Elizabeth's Hospital]], Malden Hospital, [[Memorial Hospital (Worcester)|Massachusetts Memorial Hospital]], [[Carney Hospital]], and St. Margaret's Hospital.<ref name = "Grant">{{Cite web |url=https://www.nfpa.org/-/media/Files/Public-Education/By-topic/Occupancies/NFPA-Journal-2007_CocoanutGrove-small.pdf |title=Casey C. Grant, "Last Dance at the Cocoanut Grove," National Fire Protection Association, ''NFPA Journal,'' November/December, 2007. |access-date=2018-11-10 |archive-date=2018-11-11 |archive-url=https://web.archive.org/web/20181111000303/https://www.nfpa.org/-/media/Files/Public-Education/By-topic/Occupancies/NFPA-Journal-2007_CocoanutGrove-small.pdf |url-status=dead }}</ref> MGH took 114 [[burn]] and [[smoke inhalation]] victims, and BCH received over 300.<ref name="Saffle">{{Cite journal |last=Saffle |first=J. R. |year=1993 |title=The 1942 fire at Boston's Cocoanut Grove nightclub |journal=American Journal of Surgery |volume=166 |issue=6 |pages=581–591 |doi=10.1016/s0002-9610(05)80661-0 |issn=0002-9610 |pmid=8273835 |doi-access=free }}</ref> It was estimated that one casualty arrived at BCH every eleven seconds,<ref name = "Montgomery"/> the greatest influx of patients to any civilian hospital in history.<ref>Moulton RS. ''The Cocoanut Grove Night Club fire, Boston, November 28, 1942.'' National Fire Protection Association. Boston, January 11, 1943, 1-19.</ref> Both hospitals were unusually well-prepared, as medical facilities all along the eastern seaboard had drawn up emergency plans in preparation for attacks against the [[American East Coast|East Coast]]. Boston had carried out a city-wide drill only a week earlier, simulating a [[Luftwaffe]] bombing assault, with over 300 mock casualties.<ref name = "Grant"/> At MGH, a special store of emergency supplies had been stockpiled. The fire caught both hospitals at change of shift, so that a double complement of nursing and support staff was available, in addition to volunteers who flocked to the hospitals as word spread of the disaster.<ref name = "Saffle"/>

Nonetheless, most patients died en route to the hospitals or shortly after arrival. Because no standardized system for [[triage]] yet existed in civilian [[Mass-casualty incident|mass casualty management]] in the U.S.,<ref>{{Cite journal |last=Mitchell |first=Glenn W. |orig-date=2008-09 |title=A Brief History of Triage |url=https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/abs/brief-history-of-triage/7A06DA1AE46DBBF782BD741C5F5CF4B2 |journal=Disaster Medicine and Public Health Preparedness |date=2008 |language=en |volume=2 |issue=S1 |pages=S4–S7 |doi=10.1097/DMP.0b013e3181844d43 |pmid=18769265 |issn=1935-7893|url-access=subscription }}</ref><ref>{{Cite web |url=https://www.swenurse.se/globalassets/sena/triage-in-medicine.pdf |title=Iserson K., and Moskop, J. "Triage in Medicine, Part I: Concept, History, and Types." ''Annals of Emergency Medicine,'' 2007: 49(3):275-81. |access-date=2018-11-09 |archive-date=2020-10-18 |archive-url=https://web.archive.org/web/20201018174609/https://www.swenurse.se/globalassets/sena/triage-in-medicine.pdf |url-status=dead }}</ref> precious minutes were initially wasted in attempts to [[Resuscitation|revive]] those who were dead or dying, until teams were dispatched to select the living for treatment and direct the dead to be taken to temporary [[mortuary|mortuaries]].<ref name = "Finland1"/> By Sunday morning, November 29, only 132 patients out of the 300 transported to BCH were still alive, whereas at MGH, 75 of the 114 victims had died, leaving 39 surviving patients in treatment.<ref name = "Lyons"/><ref name = "Saffle"/> Of a total of 444 burn victims hospitalized after the fire, only 130 survived.

One of the first administrative decisions made at MGH was to clear the general surgery ward on the sixth floor of the White Building and devote it entirely to victims of the fire.<ref name = "Grant"/> All victims were housed there; strict [[isolation (health care)|medical isolation]] was maintained, and a part of the ward was set aside for dressing changes and [[wound care]]. Teams of nurses and [[orderly|orderlies]] were organized for administration of [[morphine]], wound care, and respiratory treatments.<ref name = "Saffle"/>

Prior to the fire, in April 1942, MGH had established one of the area's first [[blood bank]]s, and had stocked it with 200 units of [[dried plasma]] as part of preparations for the war.<ref>Faxon NW, Churchill ED. "The Cocoanut Grove disaster in Boston: a preliminary account." ''JAMA'' 1942; 120: 1385-8.</ref> A total of 147 units of plasma were used in treating 29 patients at MGH. At BCH, where the [[Office of Civilian Defense]] had stored 500 units of plasma for wartime use, 98 patients received a total of 693 units of plasma, which included plasma donated by Peter Bent Brigham Hospital, the [[United States Navy]] and the [[American Red Cross]].<ref name = "Lyons"/> The volume of plasma used in treating victims of the fire surpassed that used during the [[attack on Pearl Harbor]].<ref name="ReferenceA">Finland M, Davidson CS, Levenson SM. "Effects of plasma and fluid on pulmonary complications in burned patients: study of the effects in victims of the Cocoanut Grove fire." ''Arch Intern Med'' 1946; 77: 477-90.</ref> In the days following the fire, 1,200 people donated over 3,800 units of blood to the blood bank.<ref name = "Grant"/><ref name = "Lyons"/>

Most survivors were discharged by the end of 1942; however, a few patients required months of [[intensive care]]. In April 1943, the last survivor from MGH was discharged. At BCH, the last casualty, a woman from [[Dorchester, Massachusetts|Dorchester]], died in May after five months of treatment for severe burns and internal injuries. Hospitals rendering service chose not to charge any of the patients for treatment. The Red Cross provided financial aid to both public and private hospitals. This was especially helpful to BCH, given its enormous influx of patients.<ref name = "Grant"/>

===Advances in the care of burn victims===
[[File:Lund-Browder chart-burn injury area.PNG|right|thumb|upright=1.3|The [[Lund and Browder chart]] was first published in 1944 and was based on experience treating victims of the Cocoanut Grove fire.]]
The fire led to new ways of caring for both burns and smoke inhalation.<ref name = "Aub"/> The team at BCH was directed by Dr. Charles Lund as senior surgeon and Dr. Newton Browder. In 1944, Lund and Browder, drawing upon their experiences in treating Cocoanut Grove victims, published the most widely cited paper in modern burn care, "Estimation of the Areas of Burns", in which a diagram for estimating burn size are presented. This diagram, called the [[Lund and Browder chart]], remains in use throughout the world today.<ref>Lund CC, Browder NC. "The estimation of areas of burns." ''Surg Gynecol Obstet'' 1944; 79: 352-8.</ref><ref name = "Lee"/>

====Fluid therapy====
Surgeons [[Francis Daniels Moore]] and [[Oliver Cope]] at MGH pioneered [[fluid resuscitation]] techniques for the burn victims, noting that the majority of patients suffered from severe hemorrhagic [[tracheobronchitis]] because of "prolonged inhalation of the very hot air and fumes which presumably contained many toxic products...and, in addition, numerous hot particles of fine carbon or similar substances."<ref name = "Finland1">Finland M, Davidson CS, Levenson SM. "Clinical and therapeutic aspects of the conflagration injuries to the respiratory tract sustained by victims of the Cocoanut Grove disaster." ''Medicine'' 1946; 25: 215-83.</ref> At the time, infusions of [[saline solution|saline]] alone were thought to "wash out" plasma proteins and increase the risk of [[pulmonary edema]]. Accordingly, patients at MGH were given a solution of equal parts of plasma and saline solution, based on the extent of their cutaneous burns, while at BCH, patients with respiratory injuries were given fluids as needed. 

Careful evaluations showed no evidence of pulmonary edema, and Finland's studies at BCH concluded that "the fluids seemed to produce obvious improvement in most instances without any apparent adverse effect on the respiratory system."<ref name="ReferenceA" /> This experience stimulated further studies of burn shock, leading to a 1947 publication by Cope and Moore of the first comprehensive formula for fluid therapy based on a calculation of the total surface area of burn wounds and the volume of urine and liquids that had been wrung out of patients’ bedsheets.<ref>Cope O, Moore FD, "The redistribution of body water and the fluid therapy of the burned patient." ''Ann Surg'' 1947; 126: 1010-45.</ref><ref name="Lee" />

====Burn care====
The standard surface burn treatment in use at the time was the so-called "tanning process" involving the application of a solution of [[tannic acid]], which created a leathery scab over the wound that protected against the invasion of bacteria and prevented the loss of bodily fluids.<ref>{{Cite journal |doi = 10.1016/S0002-9610(41)90198-8|title = Fifteen years of the tannic acid method of burn treatment|journal = The American Journal of Surgery|volume = 51|issue = 3|pages = 601–619|year = 1941|last1 = Glover|first1 = Donald M.|last2 = Sydow|first2 = Arnold F.}}</ref> This was a time-consuming process that subjected the patient to agonizing pain because of the scrubbing procedure required before the application of the chemical dyes.<ref>{{Cite journal |last1=McClure |first1=Roy D. |last2=Allen |first2=Clyde I. |orig-date=MAY 1935 |title=Davidson tannic acid treatment of burns |url=https://doi.org/10.1016/S0002-9610(35)90119-2 |journal=The American Journal of Surgery |date=1935 |volume=28 |issue=2 |pages=370–388 |doi=10.1016/s0002-9610(35)90119-2 |issn=0002-9610 |access-date=2023-05-23|url-access=subscription }}</ref>

At MGH, burns were treated with a new technique pioneered by Cope and refined by [[Bradford Cannon]]: soft gauze covered with [[petroleum jelly]] and [[boric acid]] ointment.<ref name = "Lyons"/><ref name="Smith">{{Cite web |last=Smith |first=Peter Audrey |title=Cocoanut Grove Fire Spurred Burn Care Innovation |url=https://giving.massgeneral.org/tragedy-spurred-burn-care-innovation/ |date=2021-06-02 |url-status=dead |archive-url=https://web.archive.org/web/20181111043701/https://giving.massgeneral.org/tragedy-spurred-burn-care-innovation/ |archive-date=2018-11-11 |website=Massachusetts General Hospital |language=en |access-date=2023-06-20}}</ref><ref name = "Aub">Joseph C. Aub, Henry K. Beecher, Bradford Cannon, Stanley Cobb, Oliver Cope, N. W. Faxon, Champ Lyons, Tracy Mallory and Richard Schatzki and Their Staff Associates (Massachusetts General Hospital Staff doctors). ''Management of the Cocoanut Grove Burns at the Massachusetts General Hospital''. Philadelphia, Lippincott, 1943.</ref> Patients were kept on a closed ward, and meticulous [[Asepsis|sterile technique]] was used in all patient care activities. A month later, at BCH 40 of the initial 132 survivors had died, mostly from complications from their burns; at MGH none of the 39 initial survivors died from their burns (seven died from other causes<ref name = "Grant"/>). As a result, the use of tannic acid as a treatment for burns was phased out as the standard.<ref name="Lee">{{Cite journal |last1=Lee |first1=Kwang Chear |last2=Joory |first2=Kavita |last3=Moiemen |first3=Naiem S. |date=2014-10-25 |title=History of burns: The past, present and the future |journal=Burns & Trauma |volume=2 |issue=4 |pages=169–180 |doi=10.4103/2321-3868.143620 |issn=2321-3868 |pmc=4978094 |pmid=27574647 |doi-access=free }}</ref><ref>Barbara Ravage, ''Burn Unit: Saving Lives After the Flames.'' Da Capo Press, 2009. {{ISBN|9780786738915}}</ref>

====Antibiotics====
At MGH, intravenous [[sulfadiazine]] (a drug which had only been approved for use in the U.S. in 1941<ref>[https://web.archive.org/web/20200117203243/https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=reportsSearch.process&rptName=2&reportSelectMonth=8&reportSelectYear=1941&nav FDA Approvals August 1941]</ref>) was given to all patients as part of their initial treatment. At BCH, 76 patients received [[Sulfonamide (medicine)|sulfonamides]] for an average of 11 days.<ref>Finland M, Davidson DS, Levenson SM. "Chemotherapy and control of infection among victims of the Cocoanut Grove disaster." ''Surg Gynecol Obstet'' 1946; 82: 151-73.</ref> Thirteen survivors of the fire were also among the first humans to be treated with [[penicillin]].<ref name = "Lee"/><ref name = "Lyons"/> In early December [[Merck & Co.|Merck and Company]] rushed a 32-liter supply of the drug in the form of culture liquid in which the ''[[Penicillium]]'' mold had been grown, from [[Rahway, New Jersey]], to Boston. These patients received 5,000&nbsp;[[International units|IU]] (roughly 2.99&nbsp;mg) every four hours, a small dose by today's standards, but at the time [[Antimicrobial resistance|antibiotic resistance]] was rare, and most strains of ''[[Staphylococcus aureus]]'' were penicillin-sensitive.<ref name="Levy">Stuart B. Levy, ''The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers,'' Da Capo Press, 2002: pp. 5-7. {{ISBN|0-7382-0440-4}}</ref> The drug was crucial in preventing infections in [[skin graft]]s. According to the ''[[British Medical Journal]]'':

<blockquote>Though bacteriological studies showed that most of the burns were infected, the [[second-degree burns]] healed without clinical evidence of infection and with minimal scarring. The deep burns remained unusually free of invasive infection.<ref>{{Cite journal |date=1944-03-25 |title=Lessons from the Boston Fire |journal=British Medical Journal |volume=1 |issue=4342 |pages=427–428 |issn=0007-1447 |pmc=2283836 |pmid=20785349}}</ref></blockquote>

As a result of the success of penicillin in preventing infections, the U.S. government decided to support the production and the distribution of penicillin to the armed forces.<ref name = "Levy"/>

====Psychological trauma====
[[Erich Lindemann]], an MGH psychiatrist, studied the survivors of the dead and published what has become a classic paper, "Symptomatology and Management of Acute Grief",<ref>{{Cite journal| last = Lindemann| first = Erich| author-link = Erich Lindemann| title = Symptomatology and Management of Acute Grief| journal = [[American Journal of Psychiatry]]| volume = 151| issue = 2| pages = 155–160| publisher = [[American Psychiatric Association]]| pmid = 8192191 |date=June 1994| doi = 10.1176/ajp.101.2.141}}</ref><ref name = "Smith"/> read at the Centenary Meeting of the [[American Psychiatric Association]] in 1944.

At the same time Lindemann was laying the foundation for the study of [[grief]] and dysfunctional grieving, [[Alexandra Adler]] conducted psychiatric observations and questionnaires over eleven months with more than 500 survivors of the fire, publishing some of the earliest research on [[post-traumatic stress disorder]]. More than half of the survivors exhibited symptoms of general nervousness and anxiety which lasted at least three months. Survivors who lost consciousness for a short period of time during the incident exhibited the most post-traumatic mental complications.<ref>{{cite journal |last=Vande Kemp |first=Hendrika |date=Spring 2003 |title=Alexandra Adler, 1901-2001 |url=http://www.psych.yorku.ca/femhop/Adler.htm |url-status=dead |format=reprint |journal=The Feminist Psychologist |language=en |publisher=Society for the Psychology of Women |volume=30 |issue=2 |archive-url=https://web.archive.org/web/20031222202129/http://www.psych.yorku.ca/femhop/Adler.htm |archive-date=2003-12-22 |access-date=2010-12-02}}</ref> Adler noted that 54% of survivors treated at BCH and 44% of those at MGH exhibited "post-traumatic neuroses", and that a majority of the survivors' friends and family members showed signs of "emotional upset that attained proportions of a major psychiatric condition and needed trained intervention."<ref>{{Cite journal |last=ADLER |first=ALEXANDRA |title=Neuropsychiatric Complications in Victims of Boston's Cocoanut Grove Disaster |date=1943-12-25 |url=https://doi.org/10.1001/jama.1943.02840520014004 |journal=Journal of the American Medical Association |volume=123 |issue=17 |pages=1098–1101 |doi=10.1001/jama.1943.02840520014004 |issn=0002-9955|url-access=subscription }}</ref> Adler also discovered one survivor with a lasting brain lesion who presented symptoms of [[visual agnosia]], most likely caused by exposure to carbon monoxide fumes, other noxious gases and/or a lack of sufficient oxygen.<ref>Adler, A., "Course and outcome of visual agnosia." ''Journal of Nervous and Mental Disease,'' 1950:111, 41-51.</ref>