THE TREATMENT OF WOUNDS BY FLAVINE
BMJ (Clinical Research Edition)
Wii" have seen lately in the Lanicet and BRITISH MIEDICAL .JoURNAL two articles imipugning the value of flaviue and its coiigeniers as antiseptics; and as we lhave used it largely in military practice and are colnfirmed in our good opinion of it as time passes, we tlhink it -would be sometlhing of the nature of an act of ingratitude if we allowed ani excellent wound dressinig to fall into discredit for walnt of support from its friends. The first of the articles referred to takes flavine fromii
... akes flavine fromii the laboratory point of view and criticizes the technique by wlhich its efficacy as against bacteria in vitro was established. With these points we may leave Dr. Browning an(d hlis collaborators to deal. But the second article, wlhichl appeared in the BRITISH MEDICAL JOURNAL of December 29th, 1917, and which takes us to the bedside of some fifty selected cases, we feel more competent to criticize. Its lucid exposition and fair and candid treat. ment of the observed facts make it easy to do so. Two main theses are proposed in this article. First, a comparison is made between flavine and Carrel-Daliin treatment, in which the former, though not inferior at all points, is yet made, on tile criteria chosen, to take a second place; and secondly, by histological examination flavine is shown to delay the process of repair, to allow organisms to renmain on the wound surface, and to prevent epitlhelial ingrowtlh. Now we hold that a comparison of any miietlhod witlh that of Messrs. Carrel and Dakin is not quite fair until the following facts are remembered: When these workers first showed that infected wounds could be cleansed by continuous washing with lhypochlorite solution, they also pointed out tlle great difficulties of the method, tllh imieticulous care required in the preparation of tlle reagent, in the protection of the surrounding skin, in the surgical ritual of the dressing, and so on. More than tllis, thley were the first to set the ideal of ultimate wound suture, for we are sure no English surgeon had ever thlought it possible before. Botlh these points-the difficulty of technique and the high ideal of repair--are characteristic of the Carrel-Dakin method, and explain why, though it is one of the most brilliantly successful ways of treating infected wounds in war, it is also one of the most difficult to carry out to full success. It is only in certain hands that it is really successful, and wlhen it fails it fails badly. One of us, who has opportunities of constantly visiting ten large lhospitals, is prepared to affirmn that not 10 per cent. of the surgeons whose work he sees have the requisite time in periods of stress, even thouLgh tlley possess the requisite patience of technique, to achieve anything like, for example, the success of the series of fifty eases quoted in this article. In making the comnparison between the two series, the autlhors have heavily weiglhted the scales against the Carrel-Dakin nmethod. This series is made up of " much imore seriously wounded men," including cases considered too severe for experimeental treatment with flavine, and the wounds submitted to the flavine treatment lhad previously for tlle most part been treated by the Carrel-Dakin metlhod, and yet nearly double tlhe percentage of suture cases is slhown, the nLiuber of cases evacuated healed is two and a half timi-es as muany, and so on. This is plainly a series wlichl has been in the lhanids of a master. But to any observer wlho has opportunities of seeing the Carrel-Dakin m-etlhod as performled by muanv hanids, the above results seemii a triumnph of mnethod indeed, but above all a triumlph of individual technique. Results whieh we assert can only be obtained by an expert with much time and comnparativelv few cases are contrasted with a method whlicll, to talie a phrase from meclhanics, is practically fool proof, for we suppose tlhat, allowinia adequlate previous surgical treatment, any dresser can fill a wound cavity wvith gauze dipped in 1 in 1,000 solution of flavino. We caln only say that in the many lh-uLndreds of cases (ratlher muore than 5,000 at present) so treated in the hogpitals under the command of one of us, xve lhave found that for ease of preparation and application, rapidity wvhen dealing with large numibers of cases, com-plete absence of surgical fidget, early cleaninlg of tlhe wounds, and abatement of coustitutional reaction to absorption, flavinie and its congener brilliant greein) is aln admirable applicationi under all circuimstalnces, but especially whlere surgeons arc few, timne is sllort, and wounds are many. But, even whlen contrasted witlh tlle Carrel-Dakin series, the series of fifty flavine cases does not comne badly out of the test. We niote that temperature falls early; that more than onethird reach the difficult suture ideal; and tlhat, tlhough tllere is delay in tlle process of hlealing, there is somne diminution in the local anid general reactioni to infection. We remember, of course, that tlle flavine series was in tlle same capable surgical lhands as the other scr-ies, tlhouglh this consideration must be discounted by thxe greater ease of application of flavine dressings. To slmll up our criticism: we hold that, patting aside any quiestion of the pernmanence and effectiveness of the antiseptic solitioni uised in the Carrel-Dakin treatment (though this lhas been called in question), the method itself is not of uniiversal application, entirely on account of its inlherent difficulties of technique. If this is allowed,any simpler utethod whichl can be effectively used by less skilled workers, and wlhie approaches in efficiency, as judged by the suture standard, the Carrel-Dakin method, is worthy in spite of minor drawbacks, of an extended trial in the army. We claim to have already passed through such a trial, and have made up our minds on the point. It only remains to add that in the 5,000 or more -wounds under our observation lno slkin irritation has been observed, and we suggest that it is possible that the irritation observed in the cases quoted was due to the previous treatment by the hypochlorite metlhod. Coming next to tlle histological part of the article quoted, the appearances observed in the excellently reproduced series of sectiolns given is conclusive evidenlce of a certain amount of surface destruction in wounids treated by flavine. Tllis is clinically apparent in a few cases only in our experience. In these cases a fibrinous pellicle forms in the woulnd, and we have always been used to attribute this appearance to the use of too strong solution. There are no doubt incdividual idiosyncrasies witlh tllis as witlh any other applicatioin. Flavine, unlike other antiseptics, is not reduced in power by contact witlh serum, and tlherefore the evaporationi of fluid may result in a concentrated mass action uponi the tissues. We have found that the pellicle in questionl is readily removed by the application of saline solutioni. The lethal concentration of flavine against cocci in thle presence of serum being 1 in 200,000 (Browning), we filnd the addition of hypertonic saline solution a valuable adjunct to the action of the antiseptic by producing free exudation; but allowing the fact of a microscopical layer of surface destruction, is it not a fact that all antiseptics are to some extent escharotic and produce in certain concentrations similar appearances? What we wish to know is-what is the exact clinical value of these observatiolns ! We are told that hlealing is delayed, that epithelial ingrowth is prevented, that organisms linger in the wound, and we find it extremiiely difficult to make tllese deductions from hlistological appearances square witlh our clinical experiences in thousands of cases. We are told gravely that " tlle eluployment of flavine and other dyes, as if they supplied royal roads to success, must be regarded as retrograde steps," and we go round our wards and find patients with normal temperaturLes, witlh no signs of conistitutiolnal reaction, witlh hlealthy granulating wounds, over wlichl epitlheliumu is growinig naturally, and we wonder wlhy tlle experience of the autlhors of this article was so different in fifty cases froml our own in as many lhundreds.