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Carbolic Acid Dissolved in Paraffin Oil as a Means of Preventing Sepsis in Gunshot Wounds
Prevention of S epsis
Z1Z
Gunshot Wounds
483
CARBOLIC ACID DISSOLVED I N PARAFFIN O IL AS A MEANS OF PREVENTING SEPSIS I N GUNSHOT WOUNDS . By
LIEU TEN A NT
1\/. K . ACHESON.
Roy al Army lJledi cal Corpz .
As the re sult of the publication of Sir W. Watson Cheyne's illum inating oration in the Lancet of February 27, on the treatment of wounds in war, so me experiments were undertaken at No. I Gene ral Hospital, on simil a r lines to th ose de scribed by him. Owing to stress of ordina ry routine laboratory wo rk, the limits of time, and to act ive service conditions, the work had to be considerably curtailed. A ft er going over some of the gro und already cove red by Sir 'vV. Watson Cheyne , ord inary crude paraffin oi l was adopted as bein g a promising medium f,o,r b ringi ng ant iseptics in contact with patho g enic micro-org ani sms. Carbolic · acid was di sso lved in water-free paraffin in varying percentages. The solution was then te sted in reference to it s bactericidal effect s" its diffu sibility, its power of penetration through organic sub stances, it's toxicity, its volatility and its action ·on the vitality of livin g tissues and its absorptio n by them. Local Bactericidal Action :-Thi s was found to be somewhat similar to that o f corresponding streng ths of carbolic lotion. Diffusibility.-A number o.f similar agar slopes in te st tube s of the same diameter we re thoroughly inoculated with Bacillus sttbtilis. One cub ic centimetre of different strengths of the carboli c and paraffin solution and of various other antiseptics were carefully deposited throu g h fine pipette s at the bottom of the already inoculated agar tube s without touching the agar except at the bottom oi the tube. The tubes were incubated in the upri g ht po sition for t wenty-fo ur hours at 37° C. After incubation the distance between the lowest marg in of the g r owth of the bacillus on the ag ar slopes and the mean level of the antiseptic fluid was measured in millimetres. The results on the average of a number of observations a re shown in the table on p. 484. B . subtilis was employed because of its spor.in g nature, its rapid gro wth, readily recognized app·ea rance, and the difficulty g enerally found in arresting its advance.
The Vete1'7:nary Journal. Penetration through Organ·ic Substances.-A number of round lids (ordinary tobacco tin s, &c.) were obtained. In the centre of each lid a hole was punched about the siz·e o f a shilling, over which was placed a circular layer of meat. This meat was about a quarter of an inch thick , fre-e from intermuscular septa, of homo geneou s fibre and completely filling the lid. The upper surface of the meat was inoculated with an emulsion of B. coli commttnis and B. Pyoc)laneus. The lid containing inoculated meat was then plac·ed in another li d in such a way that the floor of the upper lid did not come into contact with the floor of the lower lid. Into the lower lid was poured a few cubic centimetres of the solution to be tested. In order to bring the lower uninoculated surface of the meat in contact with the fluid of the lower tin , a pledget of cotton-wool was placed in the antiseptic Strength
Hydrarg. perchlor . .. . Tincture iodi ne Hydrogen peroxide ... Carbo lic and paraffin C resol Carbolic and paraffin Carbolic lotion Carbolic and paraffin Cresol Carbo lic olive oil Carbolic lotion Boracic lot ion saturated Paraffin oil
Distance between grow th and antiseptic
1-2,000 ...
No growth.
B.P. 20 vols . ... 2~ per cent .
20'6 "
5 2
5 2
2~ 2~
"
30mm •
19'6 " 17 " 16' 3 .. 12 12
tI
8'3 " 7·5 " [
.
Slight inhib iti on.
a pO SttlOn correspondin g to the hole o,f the upper lid . The two lids were then placed in a Petri dis-h and incubated for fo rtyeight hOUl-S at 37° C. A s thi s experiment is a very severe test, certai n preca ution s are nece ssary. All the specimens of meat should be taken from the same animal and from the same part of the animal if possible . As the meat during inoc ul ation will swell considerably, larg e Petri di she s. should be used to prevent pressure of the g lass - on the meat surface. The layers of meat should not be more than a quarter of an inch thick. Various anti septics were tested and compared with differem: strength s of the paraffin carbo lic so lution. It was again found that paraffin itself had no inhibitory action, but that even so weak a solution as the I per cent. carbolic paraffin acted as a deodorant and prevented marked decompo sition in the meat. It not only III
P 1'evention of Sepsis in Gunshot TPounds
485
penetrated the meat in the centre in the neighbourhood of the point of contact of the solution with the lower surface of the meat , but also crept up aro und the margins of t he meat at the periphery. Broadly speaking, the longer the meat was incubated in the presence of the carbo li c paraffin, the more marked was the antiseptic -effe ct. In t he case of hydrarg . perchlor. I in 1,000, hydrogen peroxide, carbo lic paste in lower strengths than IO per cent. carbolic ,o.il 2~ per cent. , the meat invariably became so offe nsive that as far as the se substances were concerned the experiment had t o be abandoned afte r thirty-six hours. As r egards tincture of io dine the results were rather interestin g. Provided 15 to 20 C.C. of the tincture were poured int o the lower tray, no decomposition OCCUlTed in the meat . With lesser quantitie s the r esu lts were 110t so sati sfactory. Unfortu nately it is inadvisable, from the point of view of toxicity, to inj ect sufficient qu antities of iodine into. a gunshot wound t o pr-e vent seps is occurrin g. Iodine must therefore be regard ed as a failu re in reference to gu nshot wounds, simp ly beca u se it may not be use d in sufficient quantitie s. There I S , however, no rea son to discard its u se in aseptic surgery. Carbolic lotion and creso l lotion beginni ng at str engths 0 f 5 per cent. were also proved to be of valu e as penetrating antisept ics and deodorants, though the effects of the carbol ic and paraffin were always found to b e roughly at least two and a half times as great. That is the action of 5 per cent. sol ution o,f cresol or carbolic lotion was about equivalent to that of the 2 per cent. carbolic and paraffin . In the case of carboli c and paraffin solution, as long as the pled get of wool remained moist in the tray beneath the meat, practically no decomposition took place in thin secti ons of the meat , except when very weak so lutions were used. The result of this experiment was strikin g as the inoculated meat reproduces pretty well the conditions found in a septic wound. Clots or dead ti ssue might be expected to be penetrated for a considerable di stance by the carbolic and paraffin solution if kept continuously pre se nt in the wound by means 01 gauze packin g and gau ze wicks. T oxicity.-One cubic centimetre of 2 per cent. ca rbolic and paraffin soluti on was injecte d subcutaneou sly into a g ui nea-pIg (350 g-rm .) wi th out ill-effect. No t oxic effect \\'as obse rved a's a
The Veterinary
'.l ournal.
result of the use of the solution in a number of septic g un shot wound s. Vo latility.-Carbo lic lotion incubated 37° C. was found to evaporate about four times as quickly as carbolic and paraffin so lution of the sa me strength. Inj1wy to th e Tissu es.--No injury or corrosive effect was observed as a res ult of the presence of the paraffin solution on raw surface s. The skin, however, was occasionally blistered . Absorption by the T issues . -The characteri stic odour of the so lution ha s been noticed emanating fr om wounds into which it had been injected twenty-four ho urs previously. Absorption is probably very slow. DiS'advan tages .--The inflammable nature of the paraffin sho uld not be dan gerou s with or dinary precaution s. Blistering of the sk in is due to the creeping nature of the paraffin, its lack o f volati lity and the intimate prolonged and continu ous contact of the carbo lic in the paraffin with the skin. Conclusions.-The pure carbolic acid which has recently been re commended causes destruction o,f tissu e at the sean of application , and the re sultin g slough may easily form a nidus, for bacterial g rowth in a wo und already devitalized and lacerated . Carbolic paste in nigh strength s may prove to~ic. It cannot be injected in any satisfactory fa shion into a wound and has little or no superiority over much weaker strengths of the carbolic and paraffin solution. The carbolic and paraffin solution is, roughly speaking, two and a half time s as penetrating, twice as diffusible, equally bactericidal and equally non-toxic, as a correspondin g aqueous so luti on of the dru g. In addition it remains mo,ist four time s as long as an equal strength of carbo lic lotion at blood heat. It is suggested that all penetrating wounds should, as soon a s possible, be injected by mean s of a g lass syrin g e with a 21 per cent. so lution of the paraffin and carbolic, care being taken to protect the skin in the manner de scribed below, and the wound should be then lightly packed with ga uze. The plug may be moi stened, if nece ssary, durin g the train or boat journey to the base ho spital. For prophylaxis the 21 per cent. so luti on is recommended, for ·treatment I per cent. Precautions.-T he solutions sho uld be made in bottles which
Prevenizon of Sepsis in Gunshot T¥ounds
487
have been carefully dried and the paraffin should be fi ltered and wate r-free . A simple way of demonstratin g the water impurity in paraffin is to add a crysta l of methylene blue, when the water lying at the bottom of the vesse l reveals its presence by the absorption of all the stain . It is necessary, however, to test for water before the carbolic is added, as carbo,l ic paraffin is a solvent of methyle ne blue . This is important as a small quantity ot water in the paraffin assimilat es t o itse lf the bu lk of the carbolic, a nd thu s a very small amount of water may constitute a very concentrated solution of carboEc acid sufficient to produce local necrosis·, and at the same time nullify' the es entia I penetrating effect of the paraffin . In the experimental treatment of wound s in hospita l with a 2 per cent. so luti on, it wa s found that blistering of that portion o.f the epidermis occurred whe re the superfluous oi l overdrained, but it was discov·e red that if the superficial area exposed to the paraffin were painted with co ll odion, allowed to dry, and the in jection then made, the ill-effects were' avoided. The re sults of the treatment in wounds already septic were ft'equently g ratifying. Speaking from the point of view of a member of the staff o,f a base ho spital, one is struck by th e lar ge percentage of wounded who on admission show comparatively little clinical ·evid·ence of being serious ly ill, but who within the course of a few days develop the mo st profound deg ree of toxicity. The problem arising iiI thi s campaign ha s been to find a suitable medi um for introducin g the antiseptic and retaining it in continuous contact with the t iss ues unti l such time as further surgical attention can be g iven to the wound. As a result of bacteriolog ical investi gation and clinical experiment in the wards of thi s ho spital, it would seem feasible that paraffin oi l should be thu s employed until a better medium is foun d.-Iottrnal of t he R. A.M.C.
The Veterinary :Journal.
Radiograph of fracture of tbe atlas in a Toy Porn, by Guy Sutton. See page 389, August issue.
Z1Z
Gunshot Wounds
483
CARBOLIC ACID DISSOLVED I N PARAFFIN O IL AS A MEANS OF PREVENTING SEPSIS I N GUNSHOT WOUNDS . By
LIEU TEN A NT
1\/. K . ACHESON.
Roy al Army lJledi cal Corpz .
As the re sult of the publication of Sir W. Watson Cheyne's illum inating oration in the Lancet of February 27, on the treatment of wounds in war, so me experiments were undertaken at No. I Gene ral Hospital, on simil a r lines to th ose de scribed by him. Owing to stress of ordina ry routine laboratory wo rk, the limits of time, and to act ive service conditions, the work had to be considerably curtailed. A ft er going over some of the gro und already cove red by Sir 'vV. Watson Cheyne , ord inary crude paraffin oi l was adopted as bein g a promising medium f,o,r b ringi ng ant iseptics in contact with patho g enic micro-org ani sms. Carbolic · acid was di sso lved in water-free paraffin in varying percentages. The solution was then te sted in reference to it s bactericidal effect s" its diffu sibility, its power of penetration through organic sub stances, it's toxicity, its volatility and its action ·on the vitality of livin g tissues and its absorptio n by them. Local Bactericidal Action :-Thi s was found to be somewhat similar to that o f corresponding streng ths of carbolic lotion. Diffusibility.-A number o.f similar agar slopes in te st tube s of the same diameter we re thoroughly inoculated with Bacillus sttbtilis. One cub ic centimetre of different strengths of the carboli c and paraffin solution and of various other antiseptics were carefully deposited throu g h fine pipette s at the bottom of the already inoculated agar tube s without touching the agar except at the bottom oi the tube. The tubes were incubated in the upri g ht po sition for t wenty-fo ur hours at 37° C. After incubation the distance between the lowest marg in of the g r owth of the bacillus on the ag ar slopes and the mean level of the antiseptic fluid was measured in millimetres. The results on the average of a number of observations a re shown in the table on p. 484. B . subtilis was employed because of its spor.in g nature, its rapid gro wth, readily recognized app·ea rance, and the difficulty g enerally found in arresting its advance.
The Vete1'7:nary Journal. Penetration through Organ·ic Substances.-A number of round lids (ordinary tobacco tin s, &c.) were obtained. In the centre of each lid a hole was punched about the siz·e o f a shilling, over which was placed a circular layer of meat. This meat was about a quarter of an inch thick , fre-e from intermuscular septa, of homo geneou s fibre and completely filling the lid. The upper surface of the meat was inoculated with an emulsion of B. coli commttnis and B. Pyoc)laneus. The lid containing inoculated meat was then plac·ed in another li d in such a way that the floor of the upper lid did not come into contact with the floor of the lower lid. Into the lower lid was poured a few cubic centimetres of the solution to be tested. In order to bring the lower uninoculated surface of the meat in contact with the fluid of the lower tin , a pledget of cotton-wool was placed in the antiseptic Strength
Hydrarg. perchlor . .. . Tincture iodi ne Hydrogen peroxide ... Carbo lic and paraffin C resol Carbolic and paraffin Carbolic lotion Carbolic and paraffin Cresol Carbo lic olive oil Carbolic lotion Boracic lot ion saturated Paraffin oil
Distance between grow th and antiseptic
1-2,000 ...
No growth.
B.P. 20 vols . ... 2~ per cent .
20'6 "
5 2
5 2
2~ 2~
"
30mm •
19'6 " 17 " 16' 3 .. 12 12
tI
8'3 " 7·5 " [
.
Slight inhib iti on.
a pO SttlOn correspondin g to the hole o,f the upper lid . The two lids were then placed in a Petri dis-h and incubated for fo rtyeight hOUl-S at 37° C. A s thi s experiment is a very severe test, certai n preca ution s are nece ssary. All the specimens of meat should be taken from the same animal and from the same part of the animal if possible . As the meat during inoc ul ation will swell considerably, larg e Petri di she s. should be used to prevent pressure of the g lass - on the meat surface. The layers of meat should not be more than a quarter of an inch thick. Various anti septics were tested and compared with differem: strength s of the paraffin carbo lic so lution. It was again found that paraffin itself had no inhibitory action, but that even so weak a solution as the I per cent. carbolic paraffin acted as a deodorant and prevented marked decompo sition in the meat. It not only III
P 1'evention of Sepsis in Gunshot TPounds
485
penetrated the meat in the centre in the neighbourhood of the point of contact of the solution with the lower surface of the meat , but also crept up aro und the margins of t he meat at the periphery. Broadly speaking, the longer the meat was incubated in the presence of the carbo li c paraffin, the more marked was the antiseptic -effe ct. In t he case of hydrarg . perchlor. I in 1,000, hydrogen peroxide, carbo lic paste in lower strengths than IO per cent. carbolic ,o.il 2~ per cent. , the meat invariably became so offe nsive that as far as the se substances were concerned the experiment had t o be abandoned afte r thirty-six hours. As r egards tincture of io dine the results were rather interestin g. Provided 15 to 20 C.C. of the tincture were poured int o the lower tray, no decomposition OCCUlTed in the meat . With lesser quantitie s the r esu lts were 110t so sati sfactory. Unfortu nately it is inadvisable, from the point of view of toxicity, to inj ect sufficient qu antities of iodine into. a gunshot wound t o pr-e vent seps is occurrin g. Iodine must therefore be regard ed as a failu re in reference to gu nshot wounds, simp ly beca u se it may not be use d in sufficient quantitie s. There I S , however, no rea son to discard its u se in aseptic surgery. Carbolic lotion and creso l lotion beginni ng at str engths 0 f 5 per cent. were also proved to be of valu e as penetrating antisept ics and deodorants, though the effects of the carbol ic and paraffin were always found to b e roughly at least two and a half times as great. That is the action of 5 per cent. sol ution o,f cresol or carbolic lotion was about equivalent to that of the 2 per cent. carbolic and paraffin . In the case of carboli c and paraffin solution, as long as the pled get of wool remained moist in the tray beneath the meat, practically no decomposition took place in thin secti ons of the meat , except when very weak so lutions were used. The result of this experiment was strikin g as the inoculated meat reproduces pretty well the conditions found in a septic wound. Clots or dead ti ssue might be expected to be penetrated for a considerable di stance by the carbolic and paraffin solution if kept continuously pre se nt in the wound by means 01 gauze packin g and gau ze wicks. T oxicity.-One cubic centimetre of 2 per cent. ca rbolic and paraffin soluti on was injecte d subcutaneou sly into a g ui nea-pIg (350 g-rm .) wi th out ill-effect. No t oxic effect \\'as obse rved a's a
The Veterinary
'.l ournal.
result of the use of the solution in a number of septic g un shot wound s. Vo latility.-Carbo lic lotion incubated 37° C. was found to evaporate about four times as quickly as carbolic and paraffin so lution of the sa me strength. Inj1wy to th e Tissu es.--No injury or corrosive effect was observed as a res ult of the presence of the paraffin solution on raw surface s. The skin, however, was occasionally blistered . Absorption by the T issues . -The characteri stic odour of the so lution ha s been noticed emanating fr om wounds into which it had been injected twenty-four ho urs previously. Absorption is probably very slow. DiS'advan tages .--The inflammable nature of the paraffin sho uld not be dan gerou s with or dinary precaution s. Blistering of the sk in is due to the creeping nature of the paraffin, its lack o f volati lity and the intimate prolonged and continu ous contact of the carbo lic in the paraffin with the skin. Conclusions.-The pure carbolic acid which has recently been re commended causes destruction o,f tissu e at the sean of application , and the re sultin g slough may easily form a nidus, for bacterial g rowth in a wo und already devitalized and lacerated . Carbolic paste in nigh strength s may prove to~ic. It cannot be injected in any satisfactory fa shion into a wound and has little or no superiority over much weaker strengths of the carbolic and paraffin solution. The carbolic and paraffin solution is, roughly speaking, two and a half time s as penetrating, twice as diffusible, equally bactericidal and equally non-toxic, as a correspondin g aqueous so luti on of the dru g. In addition it remains mo,ist four time s as long as an equal strength of carbo lic lotion at blood heat. It is suggested that all penetrating wounds should, as soon a s possible, be injected by mean s of a g lass syrin g e with a 21 per cent. so lution of the paraffin and carbolic, care being taken to protect the skin in the manner de scribed below, and the wound should be then lightly packed with ga uze. The plug may be moi stened, if nece ssary, durin g the train or boat journey to the base ho spital. For prophylaxis the 21 per cent. so luti on is recommended, for ·treatment I per cent. Precautions.-T he solutions sho uld be made in bottles which
Prevenizon of Sepsis in Gunshot T¥ounds
487
have been carefully dried and the paraffin should be fi ltered and wate r-free . A simple way of demonstratin g the water impurity in paraffin is to add a crysta l of methylene blue, when the water lying at the bottom of the vesse l reveals its presence by the absorption of all the stain . It is necessary, however, to test for water before the carbolic is added, as carbo,l ic paraffin is a solvent of methyle ne blue . This is important as a small quantity ot water in the paraffin assimilat es t o itse lf the bu lk of the carbolic, a nd thu s a very small amount of water may constitute a very concentrated solution of carboEc acid sufficient to produce local necrosis·, and at the same time nullify' the es entia I penetrating effect of the paraffin . In the experimental treatment of wound s in hospita l with a 2 per cent. so luti on, it wa s found that blistering of that portion o.f the epidermis occurred whe re the superfluous oi l overdrained, but it was discov·e red that if the superficial area exposed to the paraffin were painted with co ll odion, allowed to dry, and the in jection then made, the ill-effects were' avoided. The re sults of the treatment in wounds already septic were ft'equently g ratifying. Speaking from the point of view of a member of the staff o,f a base ho spital, one is struck by th e lar ge percentage of wounded who on admission show comparatively little clinical ·evid·ence of being serious ly ill, but who within the course of a few days develop the mo st profound deg ree of toxicity. The problem arising iiI thi s campaign ha s been to find a suitable medi um for introducin g the antiseptic and retaining it in continuous contact with the t iss ues unti l such time as further surgical attention can be g iven to the wound. As a result of bacteriolog ical investi gation and clinical experiment in the wards of thi s ho spital, it would seem feasible that paraffin oi l should be thu s employed until a better medium is foun d.-Iottrnal of t he R. A.M.C.
The Veterinary :Journal.
Radiograph of fracture of tbe atlas in a Toy Porn, by Guy Sutton. See page 389, August issue.