Flavine and Brilliant Green in the Treatment of Infected Wounds

Kai Tiaki : the journal of the nurses of New Zealand, Volume X, Issue 3, 1 July 1917, Page 153

Flavine and Brilliant Green in the Treatment of Infected Wounds

D. LIGAT

By

P.R.C.S.,

Acting Assistant Surgeon to the Middlesex Hospital.

The sharp division of opinion which exists as to the advisability of employing antiseptics in the treatment of infected wounds is probably to be explained by the fact that most of the substances in general use fall far short of the ideal in their therapeutic action. Either they are highly irritating to the tissues, or they are rendered practically inert owing to admixture with the secretions from the wound. Any substance^ which would act as a powerful bactericidal agent in wounds, and which at the same time would neither damage the reparative powers of the fixed tissue nor inhibit normal protective functions, such as phagocytosis, would satisfy a felt want in wound treatment. The recent investigations carried out in the Bland-Sutton Institute of the Middlesex Hospital by Browning, Gulbransen, Kennaway, and Thornton have indicated that there are chemical compounds with powerful antiseptic action which possess the qualification for therapeutic use in a degree greatly exceeding those commonly employed. Thus, the acridine compound flavine and also brilliant green are very strong antiseptics ; at the same time, concentrations which are powerfully bactericidal, do not harm the tissues or interfere with phagocytosis. A special feature of flavine is that its action suffers no weakening in the presence of serum, and it is powerfully bactericidal against all the common pathogenic organisms — for example, staphylococci, streptococci, both of the pyogenes and enterococcus types, and E. coli. For over a year I have employed flavine compounds and brilliant igreen in septic cases^ under my care in the Middlesex Hospital. Upwards of 150 cases have been treated, about 50 per cent, of these being war wounds. They may be divided into the following groups: (1) Wounds already thoroughly septic, showing an abundant discharge of pus; (2) injuries newly inflicted, which have not yet had time to suppurate.

In the case of suppurating wounds the procedure followed has been to secure adequate drainage by free incision when necessary, and then to irrigate with a 1 :1,000 solution of the antiseptic in normal saline; finally the wound is covered with gauze soaked in the solution, and protective applied to prevent evaporation. Where there has been a cavity it has been packed lightly with gauze soaked in the solution. As to the results seen by this method of treatment, a considerable diminution in the dischange of pus may be expected at the end of twenty-four hours. In wounds of moderate severity in which no foreign body is present and in which free drainage is secured, the suppurative process may be expected to come to an end after four or five days' treatment. Any difficulty in obtaining free access for th^ antiseptic to the infected area was overcome as far as possible by syringing the solution into the wound cavity under slight pressure, and in some cases flavine 1 :1,000 was injected into the tissues and muscle planes by a cannula; no subsequent damage to the parts was observed. A noticeable feature in the use of these antiseptics is the stimulus to early formation of granulation tissue. Within fortyeight hours the more superficial parts of the wound begin to show small firm granulations, and by the end of a week the wound may be expected to be lined by granulations. In the ease of brilliant igreen these are large, nodular, and bright red in colour, while after the use of flavine they are small and of a healthy pink colour. In both cases they are firm, do not bleed readily, and grow very rapidly. Concurrently with this the epithelium grows over the raw area, and almost from the first day may be seen creeping in from the edges of the wound. It is my experience that actual healing of the wound is markedly expedited under this treatment, the majority of cases requiring only about half the time to be anticipated by other methods.

This was well illustrated by a case of nephrectomy. An infected kidney was removed, a large drainage tube inserted, and the wound left open; secondary infection of the wound 'cavity followed, with very copious discharge of pus. Creolin fomentations were applied for four days, but no improvement resulted. Treatment was then carried out with brilliant igreen, the wound being washed out and packed with gauze soaked in the antiseptic twice a day. In four days all discharge had ceased and bright red granulations were visible covering the infected surface. The cavity, which was originally large enough to contain a man's fist, completely filled in by granulation within three weeks. On several occasions I have been able, after treatment with flavine, to undertake successfully secondary operations on infected wounds. A case of gunshot wound in the arm necessitated operation in France, a circular amputation being performed, and no skin flaps provided. When the case came under my care the stump was heavily infected. Treatment with flavine for one week sufficed to remove all discharge ; I then re-amputated immediately above the old stump, cutting skin flaps from tissues which had previously been infected; the stump has since healed healthily without suppuration. In another case the leg had been removed elsewhere, and the patient came under my care with a very septic stump. It had been treated with eusol for three weeks, but showed no definite improvement in the suppurative condition; a few granulations were present at the edges, but they were soft and flabby and bled readily on dressing. After four days ' treatment with flavine the wound had entirely ceased to discharge pus, and in the same time the granulations had altogether changed in character, being now firm and allowing of free swabbing without haemorrhage. Another noteworthy case was that of a woman with inoperable carcinoma of the breast. The igrowth broke down and became very septic. An incision was made and a large quantity of pus evacuated. An attempt was made to cleanse the condition with creolin fomentations,

but five days' treatment yielded no appreciable results. Treatment with brilliant green was then instituted, and, in addition to thorough irrigation, about one ounce of the antiseptic was poured into the wound cavity daily and left there. After fourteen days all signs of suppuration were absent, and no toxic symptoms had manifested themselves from absorption My best results have not unnaturally been obtained in superficial injuries, in which free application of the antiseptic to all parts of the infected surface was possible. I have treated a number of shrapnel wounds of such type, some of them large areas of six inches square, with universally successful results with flavine. A clean surface may always be expected in such cases in four or five days, and the rapidity with which the epithelium grows in from the edges is a very noticeable feature. The absence of any deterrent effect exerted by flavine on the process of healing and growth of epithelium was strikingly demonstrated in one case in which treatment with flavine had in four days freed a large superficial area from pus and covered it with small pink granulations ; at the end of this time the epithelium had grown in for a considerable distance. The wound was thereafter dressed with red lotion (zinc sulphate 1 gr. to water 1 oz.) and the immediate slowing up of the epithelial ingrowth was remarkable. Mention must be made of a case under my care in which the antiseptic was applied before suppuration had time to develop. The patient, a man, had all the structures on the anterior surface of the arm just above the elbow-joint severed by a pane of glass. The wound was very dirty, and in it were portions of clothing. Within three hours of the infliction of the injury the foreign bodies were removed under a general anaesthetic, and the whole wound thoroughly washed out with brilliant green; the various sutures were then carefully sutured, the muscles with linen and the nerves with fine catgut. A gauze drain was inserted but soon removed. The wound healed by first intention, and the man has now a igood arm, the result of the nerve suture being equal to that obtained after primary nerve suture under the best conditions.

My opportunities for this early application of the antiseptic before the evidence of sepsis has appeared have, so far, been few. but from such cases as that cited and others of similar nature which I have observed, I consider that results of the highest value are to be anticipated in the future by what one may term the " prophylactic M use of these antiseptics. I have used considerable quantities both of brilliant green and flavine over prolonged periods ; in some cases I had no hesitation in injecting the latter antiseptic into the tissues, and have never observed any toxic phenomena following their use. In one case, of an amputation stump treated with brilliant green, a con-

siderable rise of temperature occurred, and was thought at first to be perhaps due to absorption of the antiseptic, but blood culture yielded a pure growth of Staphylococcus aureus; imeanwhile. the stump itself -.showed very .definite improvement. Of the two antiseptics investigated I have found flavine to be the more efficient, especially in heavily infected wounds with free discharge of pus, and I now use this antiseptic exclusively for septic cases. I regard these substances as satisfying therapeutic requirements for the treatment of wounds in a manner superior to any of the antiseptics hitherto employed.* — From the British Medical Journal, Jan 20.